Workplace Rehabilitation, Injury Management, Return to Work, Occupational Health and Safety and Training Services

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Company:		*Phone

Workers' Details

Workers' Name:		Phone:
Address:		Date of Birth:	[ dd/mm/yyyy ]
		Type of Injury:
Occupation:		Date of Injury:
	Fit for suitable duties Unfit
	At work (Hours per day: )	Off work (Ceased: )
Interpreter required: Yes No		If yes. Language:
Claim No.:

Employer Details

Employer:		Phone:
Address:		Fax:
		Contact:
Email:

Insurer Details

Insurer:		Phone:
Address:		Fax:
		Contact:
Email:

Doctor's Details

Doctor:		Comments:
Address:
		Fax:
Phone:

Broker's Details

Broker:		Title Company:
Address:		Comments:
Phone:		Fax:

Occupational Rehabilitation Services

	Formulation of Rehabilitation Plan		Psychological Assessment
	Initial Needs Assessment		Pain Management Counselling
	Workplace Assessment		Critical Incident Debriefing
	Vocational Assessment		Resume Preparation
	Functional Capacity Assessment		Job Search Training / Assistance
	Section 40 Assessment		Outplacement Counselling
	Activities of Daily Living Assessment		Other:
	Driving assessment

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Training Services select one Training Services 01 Training Services 02 Training Services 03 Training Services 04 Training Services 05 Training Services 06

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