Return to Work  Referral

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

Claim Details

Claim Number

Date of Injury

Claims Agent

Case Manager Name(If Applicable)

Employer Name

Return to work Details

Currently Working (please tick)

YesNo

Return to work status (please tick)

Pre-Injury dutiesAlternative/modified dutiesUnfit for work

Referral Request

Functional Capacity Evaluation (FCE)Worksite AssessmentFit for work AssessmentErgonomic AssessmentExercise PhysiologyPhysiotherapy Pre-employment Functional

Attachment/Requirements

Work capacity certificateReferral letterOther

Please upload any workcover related documents

Browse

Please wait, files are uploading..

Submit

Save and Complete Later

×

Save and Complete Later

Your response has been saved, but not yet submitted.

To come back and continue later, please use this URL:

Copy URL

---

To receive the above link via email as well, enter your email address and click send.

Send

Back to form