Return to Work Referral Form
Thank you for visiting our website, this form is intended for Case Managers wishing to refer clients under the RTWSA Program. Once you submit the form, we will aim to contact the injured worker or nominated person within 24 hours to offer an appointment. When an appointment is secured, we will then email and notify you of this.
General Information
Worker Name:
Date of Birth:
Address:
Contact Number
Email:
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Claim Number:
Date of Injury:
Claims Agent:
Case Manager Name:
Employer Name:
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Return to work Details
Currently Working (please tick)
Yes
No
Return to work status (please tick)
Pre-Injury duties
Alternative/modified duties
Unfit for work
Referral Request:
Functional Capacity Evaluation (FCE)
Worksite Assessment
Fit for work Assessment
Ergonomic Assessment
Exercise Physiology
Physiotherapy
Pre-employment Functional
Attachment/Requirements:
Work capacity certificate
Referral letter
Other
Please upload any workcover related documents:
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