General 5 Application Form
Government Application for a Accident Leave (General Form 5)
Application for Accident Leave Under Paragraph 9:1:4 of E-Code Chapter XII
Employees who suffer an accident while performing official duties may need to apply for Accident Leave. The Application for Accident Leave under Paragraph 9:1:4 of E-Code Chapter XII is used to submit the necessary information for approval.
This guide explains the information required in the application and the supporting documents mentioned in the official form.
Source – Department of Government Printing
📋 Employee Information Required
The application requests the following employee details:
- 👤 Name and designation
- 📅 Date of appointment
- 💰 Rate of pay (daily or monthly)
- 🏢 Whether the employee is required to work on Sundays and Public Holidays
These details help identify the employee and determine eligibility under the applicable leave provisions.
🚑 Accident Details
The form requires complete information regarding the accident, including:
- 📅 Date of the accident
- ⚠️ Cause of the accident
- 📍 Place where the accident occurred
- 🛠️ Nature of the work being performed when the accident happened
Providing accurate information is important for processing the application.
🔍 Accident Inquiry
The application asks whether:
- ✅ An inquiry into the accident was conducted.
- 👨💼 The employee was on official duty at the time.
- ⚖️ The employee was not responsible for causing the accident.
The form notes that an inquiry should be conducted within one week of the accident and that inquiry notes should be attached where applicable.
📄 Workmen’s Compensation Report
The form asks whether a report on Form “Q” has been submitted to the Commissioner of Workmen’s Compensation as required under Section 57(i) of the Workmen’s Compensation Ordinance.
It also notes that if the employee has not been absent for more than seven consecutive days immediately after the accident, a Form “Q” report is not required.
🏥 Medical Certificate Requirements
A medical certificate should indicate:
- 🩺 Period of leave recommended
- 💵 Monetary value of the recommended leave
The second page further requires certification by the Medical Officer or Medical Board regarding:
- ✅ Fitness for duty
- 💊 Suitable treatment received during the leave period
- ⚖️ Whether compensation claims are likely to arise
Medical certificates that do not meet the required standards should be returned for correction before being attached to the application.
📅 Leave Information
The application includes sections for:
- 📆 Date the employee returned to work
- 📝 Period of leave already sanctioned
- 📌 Period of leave currently applied for
- 💬 Other remarks, if applicable
These sections help document the employee’s leave history and the current request.
✍️ Required Approvals
The completed application contains signature sections for:
- 👨💼 Reporting Officer
- 🏢 Head of Department
- 🏛️ Secretary to the Ministry
These approvals form part of the official processing workflow shown in the application.
📑 Documents Mentioned in the Form
The application references the following supporting documentation where applicable:
- 📄 Medical Certificate
- 🔍 Inquiry Notes
- 📋 Inquiry Report
- 📑 Form “Q” (where required)
- 🩺 Medical Board Report (if attached)
✅ Conclusion
The Application for Accident Leave under Paragraph 9:1:4 of E-Code Chapter XII is intended to record the circumstances of an employee’s accident, relevant medical recommendations, inquiry findings, and leave details before obtaining departmental approval.
Applicants should ensure that all required sections are completed and that the supporting documents referenced in the form are attached where applicable.
