RAPPORT u APPLIKAZZJONI g˙all-Benefiççju ta’ Marda / Kundizzjoni Medika relatata ma’ Xog˙ol
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RAPPORT ta’ Marda / Kundizzjoni Medika relatata ma’ Xog˙ol Awtorità g˙as-Sa˙˙a u s-Sigurtà fuq il-Post tax-Xog˙ol 38, Triq l-Ordinanza, Valletta VLT 2000 Tel: 2590 3000 Fax: 2590 3001 email: social.security@gov.mt website: http://www.msp.gov.mt u APPLIKAZZJONI g˙all-Benefiççju 17, Edgar Ferro Street, Pietà, PTA1533 Tel: 2124 7677-8 Fax: 2123 2909 email: ohsa@gov.mt website: http://www.ohsa.org.mt Il-formola waslet f’dan l-Uffiççju f’din id-data: PARTI 1. TIMTELA’ MILL-PERSUNA LI QED TAGÓMEL IT-TALBA / RAPPORT [A] Skop ta’ din il-formola: Ag˙mel sinjali (4) kif applikabbli: Talba g˙all-Benefiççju g˙all-Korriment min˙abba marda jew kundizzjoni medika lid-DiviΩjoni tas-Sigurtà Soçjali. Talba g˙al G˙otja/Pensjoni tal-Korriment min˙abba marda jew kundizzjoni medika lid-DiviΩjoni tas-Sigurtà Soçjali. Rapport dwar marda jew kundizzjoni relatata max-xog˙ol lill-Awtorità dwar is-Sa˙˙a u s-Sigurtà fuq ix-xog˙ol. Talba kemm g˙all-Benefiççju/G˙otja/Pensjoni g˙all-Korriment u Rapport dwar marda jew diΩabilità relatata ma’ korriment fuq il-post tax-xog˙ol. Rapport lill-Awtorità dwar is-Sa˙˙a u s-Sigurtà fuq ix-xog˙ol minn min i˙addem dwar marda jew kundizzjoni relatata max-xog˙ol. [B] Tag˙rif dwar l-applikant Nru. tal-Karta ta’ l-Identità: Nru. tas-Sigurtà Soçjali: Isem: Kunjom: Nru. tal-Karta ta’ l-Identità tal-Konjugi (jekk japplika): Isem il-Konju©i: Il-Konju©i qed ta˙dem full time? Kunjom il-Konju©i: IVA Ag˙mel sinjali (4) kif applikabbli: LE Indirizz: Data tat-Twelid: Sess: Nazzjonalità: Stat: persuna wa˙edha miΩΩewwe© / a separat/a u i/tmantni ’lil mara / lir-ra©el Ìenitur Singlu separat/a u ma j/tmantni ’lil mara / lir-ra©el Numru tat-Telefon: Numru tal-mobile: Numru tal-Fax: E-Mail: Immarka (3) din il-kaxxa jekk trid tirçievi notifika permezz tal-SMS dwar il-˙las ta’ benefiççji soçjali. Immarka (3) din il-kaxxa jekk trid tirçievi informazzjoni u a˙barijiet permezz tal-e-mail jew l-SMS mid-DiviΩjoni tasSigurtà Soçjali. Impjieg: Impjegat G˙al rasi Part-Time Full-Time Tip ta’ xog˙ol li tag˙mel Na˙dem b’roster / shift ˙ames jew sitt ijiem fil-©img˙a Ma na˙dimx nhar ta’ NI 30 - App_Rep_WorkDis_m v3.3 u [C] Tag˙rif dwar il-post u l-ambjent li wassal g˙al marda jew kundizzjoni medika i. Talba g˙al G˙otja/Pensjoni tal-Korriment: Il-Kundizzjoni jew marda li qed tbati minnha hi riΩultat ta’ xi korriment fuq il-post tax-xog˙ol? IVA LE Jekk IVA u kont g˙amilt talba g˙all-Benefiççju g˙all-Korriment, timliex mistoqsijiet (ii) u (iii) ta’ din it-taqsima. ii. Tag˙rif dwar il-post u l-ambjent tax-xog˙ol: Iddeskrivi fil-qosor il-post tax-xog˙ol li wasslet g˙all-kundizzjoni jew marda: (eΩempju: fabrika jew workshop, store, tarzna, sit ta’ kostruzzjoni, lukanda jew restaurant, sptar, etç) iii. X’wassal g˙all-kundizzjoni jew marda: Iddeskrivi x’wassal g˙all-kundizzjoni jew marda: (eΩempju: problema fl-eletriku, spluΩjoni jew nar, ˙ru© ta’ gass, ksur ta’ g˙odda jew apparat, daqqa ta’ xi o©©ett, xi ˙sara f’xi makna, xi waqa’ jew Ωelqa, ©ejt espost g˙al xi kimika, etç) iv. Tag˙rif ie˙or dwar il-post tax-xog˙ol: Numru tal-P.E.: VAT No.: Indika d-daqs ta’ l-intrapriza fit-tabella hawn ta˙t billi tag˙mel sinjal (3) Daqs ta’ l-IntrapriΩa 0 impjegati (tinkludi self-employed li ma j˙addmu ’l ˙add mag˙hom) 1 - 9 impjegati 10 - 49 impjegat 50 - 249 impjegat 250 - 499 imjegat 500 impjegat jew iktar Daqs ta’ l-IntrapriΩa mhux mag˙ruf IVA L-impjegat da˙al lura g˙ax xog˙ol? Jekk IVA, imla wkoll id-dikjarazzjoni li ©ejja: Niddikjara li l-persuna hawn fuq imsemmija re©g˙et bdiet ta˙dem filwara li ma rraportatx g˙ax-xog˙ol minn Firma tal-Principal sa Data LE [D] Pagament Il-benefiççju g˙andu ji©i ddepoΩitat il-Bank f’kont Savings jew Kurrenti imma mhux kont ta’ self. Bank: Nru tal-Kont: Dikjarazzjoni ta’ l-Applikant Jien hawn ta˙t iffirmat nikkonferma: a) li jiena qed inbati minn marda jew kundizzjoni relatata max-xog˙ol, b) li t-tag˙rif li jidher f’Parti 1 ta’ din l-applikazzjoni huwa korrett. Naf, li fil-kaΩ ta’ talba g˙all-Benefiççju/G˙otja/Pensjoni tal-Korriment, jekk ma nibg˙atx din l-applikazzjoni lid-Direttur (Benefiççji) fi Ωmien 10 ijiem mid-data tad-disgrazzja nista’ nitlef id-dritt g˙all-Benefiççju. Jiena nawtorizza lid-DiviΩjoni tas-Sigurtà Soçjali biex tg˙addi informazzjoni dwar il-kaΩ tieg˙i lill-Awtorità dwar isSa˙˙a u s-Sigurtà fuq il-post tax-Xog˙ol skond kif ikun me˙tie© g˙al-©bir ta’ l-istatistika. Firma ta’ l-Applikant Data PARTI 3. TIMTELA’ F’KAÛ TA’ IMPJEGAT FIS-SETTUR PUBBLIKU G˙all-uΩu tal-Kap tad-Dipartiment (fejn applikabbli) “Injury / Ordinary Sick Leave” approvat (aqta’ fejn ma japplikax). Firma tal-Principal Data PARTI 4. TIMTELA’ MIT-TABIB LI JEÛAMINA LILL-PERSUNA EΩaminajt lill-persuna korruta u niççertifika li qed tbati mill-kundizzjoni / marda kif indikat fit-Tabelli A u B hawn ta˙t. Fl-opinjoni tieg˙i l-persuna ser tibqa’ nkapaçi g˙ax-xog˙ol g˙all-anqas sa (jiem/gimg˙at/xhur) o˙ra. TABELLA A - Mard / Kundizzjonijiet ikka©unati min˙abba xog˙ol It-Tabib hu mitlub jindika [3] t-tip ta’ korrimnet skond it-Tabella. TIP TA’ MARD / KUNDIZZJONIJIET Cancers Liver Cancer Cancer of the Nasal Cavity Cancer of the Accessory Sinuses Laryngeal Cancer Lung Ksur Cancer ta’ l-G˙adam Skin Cancer Mesothelioma Bladder Cancer Leukaemia Precancerious Skin Lesions Respiratory Diseases Asthma Allergic Rhinitis Allergic Alveolitis Nasal Ulcerations Nasal Perforation Chronic Bronchitis Asbestosis Diffuse Thickening of the Pleura Pleural Plaques Pleural Effusion Coal Workers’ Pneumoconiosis Silicosis Pneumoconiosis associated with Tuberculosis Pneumoconiosis due to other silicates Byssinosis Hard Metal Disease Neurological Diseases Carpal Tunnel Syndrome Toxic Encephalophaty Polyneurophaty Diseases of the Sensory Organs Cataract Noise-indused Hearing Loss Cardiovascular Diseases Raynaud’s Syndrome Skin Diseases Allergic Contact Dermatitis Irritant Contact Dermatitis Unspecified Contact Dermatitis Contact Urticaria Acne Muscoloskeletal Diseases Arthrosis of the Elbow Arthrosis of the Wrist Degeneration Lesions of the Meniscus (knee) Bursitis of Elbow Bursitis of the Knee Tenosynovitis of the Hand and the Wrist Medical Epicondylitis (elbow) Lateranl Epicondylitis (elbow) Infections Tubercolosis Brucellosis Erysipeloid Hepatitis A Hepatitis B Hepatitis C Hepatitis E Other Specific Hepatitis HIV Ancylostomiasis Leptospirosis Additional Infectious Diseases Cholera Typhoid and Parathyphoid Fever Salmonellosis Shigellosis Other Bacterial Intestinal Infection Amoebiasis Tularaemia Anthrax ikompli ... Additional Infectious Diseases (continued) Tetanus Diphteria Erysipelas Borreliosis Ornithosis Avian Chlamydiosis Q Fever Rickettsiosis Poliomyelitis Rabies Haemorrhagic Fever Varicella Measles Rubella Mumps Dermatophytosis Malaria Coding of the Toxic and Irritant Effects Hemolytic Anaemia Anemia Secondary Thrombocytopenia Agranyloctosis and Neutropenia Bronchitis (Acute) or Pneumonitis Pulmonary Oedema Upper Respiratory Inflammation Reactive Airways Dysfunction Syndrome Pulmonary Fibrosis Toxic Liver Disease Tubulo-Interstitial Kidney Diseases Chronic Renal Failure Colic and other Gastrointestinal Symptoms SEVERITY OF THE DESEASE Severity of the desease unknown Temporary incapacity to work 0 - 3 days lost 4 - 6 days lost 7 - 13 days lost 14 - 20 days lost At least 21 days lost, but less than 1 month At least 1 month lost, but less than 3 months At least 3 months lost, but less than 6 months 6 months or more lost Permanent incapacity to work Permanent incapacity without pension, level of disability unspecified Level of disability, 9 % or less Level of disability, from 10% to 14% Level of disability from 15% to 19% Level of disability from 20% to 29% Level of disability from 30% to 49% Level of disability, 50% or more or pension Coding of the Toxic and Irritant Effects Death Severity of Disease not elsewhere mentioned ikompli ... THE MAJOR GROUPS OF EXPOSURE FACTORS CAUSING THE OCCUPATIONAL DISEASE Chemical Agents Physical Agents Biological Agents Biomechanical Exposure Factors Psychosocial Exposure Factors Industrial Exposure Factors, Materials and Products PRODUCT CONTAINING THE EXPOSURE AGENT WHICH CAUSED THE OCCUPATIONAL DISEASE Absorbent and adsorbent Adhesives, binding agent aerosal propellants Anti-condensation agents Anti-freezing agents Anti-set-off and anti-adhesive agents Anti-static agents Bleaching agents Cleaning / Washing agents Colouring agents Complexing agents Conductive agents Construction materials Corrosion inhibitors Cosmetics Cutting fluids Dustbinding agents Electromechanical components Electroplanting agents Explosives Fertilizers Filters Fixing agents Flame retardants and extinguishing agents Flotation agents Flux agents for casting joining materrial Foaming agents Fuels Fuel additatives Grinding material Heat transferring agents Hydraulic fluids and additatives Impregnation material Insulating material Intermediates Laboratory chemicals Lubricants and additatives Odours agents Oxidising agents Paint, lacquers and varnishes Pesticides agricultural Non-agricultural pesticides and preservatives PH-regulation agents Pharmaceuticals Photochemicals Process regulators Radioactive agents Reducing agents Reprographic agents Semiconductors ikompli ... Softeners Solvents Stabilizers Surface-active-agents Surface treatment Tanning agents Viscosity adjusters Vulcanising agents Welding and Soldering agents Domestic animals Wild animals Products of animal origin Waste of animal origin Waste water Pointed or cutting medical material Brittle medical material (glass etc.) Other medical instruments Products for bacteriology or biology laboratories Blood and other human liquids Other human tissues Patient Other use categories Isem it-tabib b’ITTRI KBAR: Firma tat-Tabib Numru tal-Kunsill Mediku Data Dikjarazzjoni dwar il-Protezzjoni u l-Privatezza tad-Data Id-DiviΩjoni tas-Sigurtà Soçjali ΩΩomm dik l-informazzjoni kollha li hija relevanti biex tag˙ti s-servizzi me˙tie©a lil dawk il-persuni li jikkwalifikaw g˙al xi assistenza, benefiççju jew pensjoni mhux kontributorja, skont l-Att dwar is-Sigurtà Soçjali (Kap. 318). Id-DiviΩjoni tista’ tivverifika l-informazzjoni li inti ssottomettejt kif jipprovdi l-artiklu 133 (b) tal-Att dwar is-Sigurtà Soçjali sabiex tiΩgura l-eΩattezza fir-rigward tat-talba. Id-data personali tista’ ting˙ata lil dipartimenti jew terzi partijiet, li jistg˙u jkollhom aççess g˙ad-data personali tieg˙ek kif tippermetti l-li©i. Fil-©lieda kontra u l-prevenzjoni tal-frodi, id-DiviΩjoni tista’ tg˙addi lil istituzzjonijiet barranin ta’ benefiççji, l-informazzjoni personali kif stipulat fi trattati internazzjonali u / jew ftehim bilaterali li Malta tag˙mel parti minnhom. Ting˙ata risposta dwar ir-riΩultat tal-applikazzjoni tieg˙ek wara li din tkun mist˙arr©a. Biex tipprote©i l-privatezza tieg˙ek, id-DiviΩjoni tas-Sigurtà Soçjali tittratta l-informazzjoni personali tieg˙ek skont l-Att dwar il-Protezzjoni u l-Privatezza tad-Data (Kap. 440). Int tista’ tikteb biex tkun taf x’informazzjoni personali g˙andha dwarek id-DiviΩjoni, u eventwalment titlob biex l-informazzjoni ti©i korretta jew fejn applikabbli tit˙assar informazzjoni li mhix korretta, b’referenza g˙at-talba li g˙amilt. Din ittalba trid tintbag˙at lil: “Kontrollur ta’ Data Personali” f’din id-DiviΩjoni u azzjoni neçessarja tittie˙ed mill-aktar fis possibli. Meta tikteb f’dan ir-rigward, jekk jog˙©bok niΩΩel in-numru tal-karta tal-identità tieg˙ek, in-numru tas-sigurtà soçjali tieg˙ek, ismek, l-indirizz, kif ukoll xi dokumenti o˙ra li jistg˙u jkunu me˙tie©a biex nidentifikaw il-kaΩ tieg˙ek.
