Workers' Compensation and Injury Management Amendment Regulations 2014 (WA)
| 820 | GOVERNMENT GAZETTE, WA | 25 March 2014 |
Management Amendment Regulations 2014.
WC301*
Workers' Compensation and Injury Management Act 1981
Workers' Compensation and Injury
Management Amendment Regulations 2014
Made by the Governor in Executive Council.
1. Citation
These regulations are the Workers' Compensation and Injury
25 March 2014 GOVERNMENT GAZETTE, WA 821 2. Commencement
These regulations come into operation as follows -
(a) regulations 1 and 2—on the day on which these regulations are published in the Gazette; (b) the rest of the regulations - on 1 July 2014. 3. Regulations amended
These regulations amend the Workers' Compensation and Injury
Management Regulations 1982.4. Regulation 6A amended
In regulation 6A(2) delete "is to" and insert:Must
Note: The heading to amended regulation 6A is to read:
Form of first certificate of capacity
5. Regulation 7 amended
In regulation 7(1) delete "medical certificate" (each occurrence) and insert:
certificate of capacity
6. Regulation 7A inserted After regulation 7 insert:
7A. Form of progress certificate of capacity
Form 4A in Appendix 1 is prescribed as a certificate for the purposes of section 6 1(1) of the Act.
7. Regulation 8 amended
In regulation 8(1), (2) and (3) delete "First Medical Certificate" and insert:
first certificate of capacity
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8. Appendix I amended
(1) In Appendix I Form 2B delete "first medical certificate" and insert: first certificate of capacity (2) In Appendix I Form 2B delete "medical certificate/s" and insert: certificate/s of capacity (3) Delete Appendix I Form 3 and insert:
Form 3
[r. 6A and 7(1)]
Workers' Compensation and Injury Management Act 1981
(Sections 57A(1)(b), 57B(1)(b) and 61(1))
FIRST CERTIFICATE OF CAPACITY
1. WORKER'S DETAILS
First name Last name
Date of birth I / Phone Mobile
Address L 2. EMPLOYMENT DETAILS
Worker's job title Employer's name Employer's address 3. CONSENT AUTHORITY I consent to any medical practitioner who treats me (whether named on this certificate or not) to discuss my medical condition with my employer, insurer and other medical or allied health professionals for the purpose of my claim for workers' compensation and return to work options.
Worker's Print name
signature
Date
4. WORKER'S DESCRIPTION OF INJURY
Date of injury
What happened?
Worker's symptoms
25 March 2014 GOVERNMENT GAZETTE, WA 823 5. MEDICAL ASSESSMENT
!)ate of this assessment I I Clinical findings Diagnosis Ihe injury is consistent withworker's description
of how injury occurred [I] yes no uncertain
The injury is: a new condition a recurrence of a pre-existing condition 6. WORK CAPACITY Worker's usual duties Having considered the health benefits of work, I find this worker to have:
[III] full capacity for work from / / but requires further treatment
some capacity for work from I I to / I performing
pre-injury duties modified or alternative duties workplace modifications
pre-injury hours modified hours of irs/day days/wk
LI] no capacity for any work from / I to / I (outline clinical reasons below) Worker has capacity to:
(Please outline the )Porker's physical and/or psychosocial capacity - refer to explanatory notes for examples. Where there is no capacity for work please provide clinical reasoning.) lift upto kg Il Lip to nuns
tand up to mills walk up to m work below shoulder height
7. INJURY MANAGEMENT PLAN
Activities/interventions Purpose/goal
(likely change in symptoms. function, activity and work
participation)
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I would like: more information about available duties a RTW program to be established
1-1 to be involved in developing the RTW program
Examples of injury management activities/interventions include:
• further assessment - diagnostic imaging, medical specialist consults. workyite assessment;
• intervention -physiotherapy, clinical psychology, exercise physiology, prescribed medications. workplace mediation:
•
return to work planning - identify suitable duties, establish return to work program. S. NEXT REVIEW DATE
Worker does not need to be reviewed again (FIRST and FINAL certificate of capacity)
I will review worker again on / I (If greater than 14 days. please provide
clinical reasoning)
(ominents
9. MEDICAL PRACTITIONER'S DETAILS
Name AHPRA no. MED Address
SignaturePhone Fax Date (4) Delete Appendix I Form 4 and insert:
Form 4
[r. 7(1)]
Workers' Compensation and Injury Management Act 1981
(Section 6 1(1))
FINAL CERTIFICATE OF CAPACITY
1. WORKER'S DETAILS
First name Last name Date of birth Claim no. Phone Address
25 March 2014 GOVERNMENT GAZETTE, WA 825 2. EMPLOYER'S DETAILS
Employer's name Employer's phone Employer's address 3. MEDICAL ASSESSMENT
Date of this assessment I / Date of injury I / 1-1 The worker's condition is unlikely to change substantially in the next 12 months.
4. WORK CAPACITY
Having considered the health benefits of work, I find this worker to have:
full capacity for work from I I but requires further treatment (specifics below)
as outlined below: 11 hours per day and
capacity for work performing days per week from I I (Please outline the )Porker's physical and/or psychosocial capacity for work, functional limits.
ongoing needfor workplace modt/Ications, and/orfi,rther treatment needs)
1-1 lift up to kg ________
Sit Ut) to minS stand up to mills walk up to
m ________ work below shoulder height
1-1 The worker's incapacity is no longer a result of the injury.
5. REASON FOR CAPACITY/INCAPACITY
Please outline your clinical reason for the worker's capacity/incapacity:
6. MEDICAL PRACTITIONER'S DETAILS
Name AHPRAno. MED Address
Signature'hone Fax / Date
(Practice stamp - optional)
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Form 4A
[r. 7A]
Workers' Compensation and Injury Management Act 1981
(Section 6 1(1))
PROGRESS CERTIFICATE OF CAPACITY
1. WORKER'S DETAILS
First name Last name
Date of birth / / Claim no,
Phone Address 2. EMPLOYER'S DETAILS Employer's name Employer's phone Employer's address 3. MEDICAL ASSESSMENT Date of this assessment Date of injury Diagnosis 4. PROGRESS REPORT
Activities/interventions Actual outcome (change in symptoms, Still requtred*
function, activity and work participation) — —
Yes No Yes No Yes No Yes No Yes No
Yes No
* (If management activitieslinterventions are still required, please also list them in Section 6 "Injury
management plan" )
1-1 Other factors appear to be impacting recovery and return to work. Comment
5. WORK CAPACITY
Worker's usual duties
Having considered the health benefits of work, I find this vorler to have:
full capacity for work from / " hut requires further treatment
some capacity for work from / / to / / performing
pre-injury duties modified or alternative duties workplace modifications
25 March 2014 GOVERNMENT GAZETTE, WA 827
pre-injury hours modified hours of his/day days/wk no capacity for any work from I I / / (outline clinical reasons below)
to
Worker has capacity to:
(Please outline the worker's physical andlor psychosocial capacity - refer to explanatory notes for examples. Where there is no capacity for work, please provide clinical reasoning.) lift tip to kg Sit UI) to mins stand up to mi us walk up to work below shoulder height
6. INJURY MANAGEMENT PLAN
Activities/interventions Purpose/goal
(likely change in symptoms, function, activity and work
participation)I support the RTW program established by the employer/insurer/WRP dated / I I would like more information about available duties I would like to be involved in developing the RTW program Please engage a workplace rehabilitation provider (ifyou have made a referral, provide name
and contact details below) Examples of injury management activities/interventions include:
further assessment - diagnostic imaging, medical specialist consults, worksite assessment: intervention -physiotherapy, clinical psychology, exercise physiology, prescribed medications.
workplace mediation;
return to work planning - identify suitable duties, establish return to work program. 7. NEXT REVIEW DATE
1-1 I will review worker again on / I (If greater than 28 days. please provide clinical reasoning) Comments
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8. MEDICAL PRACTITIONER'S DETAILS
Name AFIPRA no. MED L cidre,s Signature
Fax Date / / (Practice stamp — optional)
(5) In Appendix I Form 5 delete "medical certificates— and insert:
certificates of capacity
R. KENNEDY, Clerk of the Executive Council.
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