Injury checklist
(for worker injuries only) Please complete as much as possible.
Key details
*
Rows
Fill in responses below
Worker's full name:
Worker's contact details:
Occupation at the time of injury:
Location:
Date of injury:
Nature of injury:
Manager/supervisor name:
Manager's contact details:
Treating doctor's name:
Doctor's contact details:
First contact and claim lodgement process
Rows
Yes
NO
NA
Senior management advised of injury
Accident investigated
Corrective actions taken and outcome discussed with worker
Inital interview conducted with worker
Claim lodged with worker: Phone report claim to claims agent
** record the date of claim below
Forward Work Capacity Certificate and last 12mths of worker's pay history to claims agent
Worker provided with injury pack (travel/chemist form, rights/responsibilities information)
Worker asked to sign medical authority (discuss confidentiality)
** Date the claim lodged with worker
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Follow-up activities
Work Capacity Certificate details
Capacity for work discussed and suitable duties identified
Concerns and/or potential barriers to return to work expressed and addressed
Special needs identified (e.g. capacity to drive, interpreter needed)
Contact claims agent and advise of actions taken to date
Rows
Yes
No
Establish a confidential file; keep notes of all communication, actions and decisions
Letter to doctor sent with a copy of signed medical authority
Worker understands the nature of their injury, treatment needs, expected outcome and are happy with their treatment plan and providers involved?
Specialist/other treatment providers involved. Please list.
Rows
Yes
No
NA
Prepare recovery/return to work plan and forward to claims agent for approval
Submit
Should be Empty: