n° 50513#06

This medical certificate must be used for employees, agricultural self-employed individuals (farm operators or agricultural business leaders, collaborators
of exploitation or agricultural enterprise, family helpers, partners of exploitation) victims of workplace accidents or commuting accidents, diseases
professional (within or outside the tables - Article L.461-1 of the Social Security Code), relapses or when he
new lesions occur that had not been mentioned on the initial certificate.

You need to complete the information regarding the victim and the employer using the information provided by the victim.

If the victim's condition requires a work stoppage, you must also complete the 'work stoppage notice' form, the present
form not allowing the prescription of a work stoppage.

You address directly within 24 hours to the organization to which the victim belongs (article L.441-6 of the code of)
social security).

It must be handed over to the victim.

The date of the first medical observation is the date on which the symptoms or lesions revealing the disease were observed.
for the first time by a doctor even if the diagnosis was established only later. It may concern the date of establishment
of the certificate.

Elements justifying the date of the first medical observation:

If this date differs from the date of issuance of the certificate, please indicate the elements that allow you to determine it: the date
of prescription of a medical examination, the date of the first sick leave related to the pathology, the date of the start of the long-term illness:
in connection with the pathology, and specify if possible, the name of the doctor who noted the lesions or symptoms.

Accurately describe the victim's condition, the location, the nature of the injuries or illness with the observed symptoms, the laterality.
where applicable.
When establishing the final medical certificate, describe the sequelae.

Predictable consequences:
Indicate if treatment is necessary and the expected duration.
This data, informative, does not condition the victim's right to reimbursement.

In case of healing or consolidation, precisely indicate the definitive consequences of the accident or illness in the
section 'detailed observations'.
It is possible, upon the recommendation of the attending physician, to continue care if necessary after consolidation. This possibility is
subject to the agreement of the consulting practitioner.

They are sent directly by the practitioner to the organization to which you belong.

You keep the goods.

NOTICE CM-BIS S6909f

 (check only one box) Section 1, to be addressed
by the practitioner to
n° 11138*06 initial new lesion(s) the organism in
CM-BIS the 24 hours
final relapse

(articles L.441-6, L.461-5, R.441-7, R.441-10, R.441-16 and R.461-9 of the Social Security Code)
CDEFGHIJKLMNOP

regime : general agricultural other which one?

registration_number
last name (of birth, followed, if applicable, by the common name) :
first_name
address where the victim can be visited (if different from their usual address):
postal code: city phone number:
building staircase floor : apartment access code for the residence:

What is it about?

of a workplace accident? date

or
from an occupational disease? date of the first medical finding: see notice

: see notice
Elements justifying the choice of the date of first medical observation (to be filled out only in the case of the initial medical certificate)

Hello World

name, first name or company name:

address :
phone number: email :

• (seat, nature of injuries or occupational disease, laterality if applicable, functional sequelae)

see notice

• predictable consequencessee notice

predictable care until date :

• (to be filled in only in case of final certificate) see notice

healing date :
consolidation with sequelae date :

identification of the practitioner identification of the structure

nstraifm
( eandansltame) (companynameandaddressoftheoffice,establishment)

structurenumber
identifier (AM,FINESSorSIRET)

date practitioner's signature

In accordance with European Regulation No. 2016/679/EU of April 27, 2016, and the "Data Protection and Freedom" law of January1978
6. modified, you have
of a right to access and rectify data concerning you with the Director of your health insurance organization or their Delegate
to Data Protection.
In case of difficulties in the implementation of these rights, you can file a complaint with the Commission National Information and Liberties.

CM-BIS S6909f
 (check only one box) Part 2, to be sent
by the practitioner to
No. 11138*06 initial new lesion(s) the organism in
CM-BIS the 24 hours
final relapse administrative service

(articles L.441-6, L.461-5, R.441-7, R.441-10, R.441-16 and R.461-9 of the Social Security Code)
tRddZptyZ

diet : general agricultural other which one?

registration number:
last name (of birth, followed, if applicable, by the surname) :
first name
address where the victim can be visited (if different from their usual address):
postal code: city : phone number:
building staircase floor : apartment access code of the residence:

is it about:
of a workplace accident? date
you
of an occupational disease? date of the first medical observation: see notice

: see notice
Elements justifying the choice of the date of the first medical observation (to be filled in only in the case of initial medical certificate)

Hello world

last name, first name or business name:

address :
phone number: email :

• (seat, nature of injuries or occupational disease, laterality if applicable, functional sequelae)

see the notice

• predictable consequencessee notice

predictable care until date :

• (to be filled in only in case of final certificate) see notice

healing date :
consolidation with sequelae date :

identification of the practitioner identification of the structure

nstraifm
( eandansltame) (companynameandaddressoftheoffice,establishment)

structurenumber
identifier (AM,FINESSorSIRET)

date practitioner's signature

In accordance with European Regulation No. 2016/679/EU of April 27, 2016, and the 'Informatics and Freedoms' law of January 1978
6 modified, you have
of a right of access and rectification of data concerning you with the Director of your health insurance organization or his Delegate
to Data Protection.
In case of difficulties in exercising these rights, you can file a complaint with the Commission. National Commission on Informatics and Liberty.

CM-BIS S6909f
 (check only one box) Section 3, to be retained
by the victim
n° 11138*06 initial new lesion(s) (to bring during
CM-BIS each consultation
final relapse

(articles L.441-6, L.461-5, R.441-7, R.441-10, R.441-16 and R.461-9 of the social security code)

diet: general agricultural other which one?

registration number :
last name (of birth, followed, where appropriate, by the name used) :
first name:
address where the victim can be visited (if different from their usual address):
postal code: city phone_number
building staircase floor: apartment access code of the residence:

What is it about:

of a work accident? date

you
from an occupational disease? date of the first medical observation : see notice

: see notice
Elements justifying the choice of the date of first medical observation (to be filled out only in case of initial medical certificate)

Hello World

name, first name or company name:

address:
telephone_number email

• Seat, nature of injuries or occupational disease, laterality if applicable, functional sequelae

see notice

• predictable consequencessee notice

predictable care until date :

• (to be filled in only in case of final certificate) see notice

healing date :
consolidation with sequelae date :

identification of the practitioner identification of the structure

(nameandsurname) (companynameandaddressoftheofice,oftheestablishment)

structurenumber
identifier (AM,FINESSorSIRET)

date practitioner's signature

In accordance with European Regulation No. 2016/679/EU of April 27, 2016 and the 'Data Protection Act' of January 6 1978 modified, you have
of a right of access and rectification of the data concerning you with the Director of your health insurance organization or its Delegate
to Data Protection.
In case of difficulties in the application of these rights, you can file a complaint with the Commission National Computing and Freedoms.

CM-BIS S6909f