Formulaire

Accident at work Medical Certificate - Occupational Disease (Form 11138*0)

Cerfa 11138*0 (S6909c)

This medical certificate must be used for employees, farm managers or agricultural companies who are victims of accidents at work, journeys, occupational diseases or relapses.

The information concerning the victim and the employer shall be supplemented by the practitioner using the information provided by the victim.

Panels 1 and 2 must be sent directly by the practitioner within 24 hours to the body on which the victim depends. Part 3 and the work stoppage certificate are to be given to the victim.

Contains Package Leaflet No 50513#05

Warning  

this version is a specimen, which is provided for information purposes only. The original form must be obtained from the CPAM on which the practitioner depends.

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    Émetteur du formulaire administratif : National Health Insurance Fund (Cnam)

    Verified 04 July 2022 - Directorate for Legal and Administrative Information (Prime Minister)