Workers' Compensation and Rehabilitation Amendment Regulations 1999 (WA)

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WESTERN 1529
AUSTRALIAN
GOVERNMENT
PERTH, TUESDAY, 13 APRIL 1999 No. 57 SPECIAL

PUBLISHED BY AUTHORITY JOHN A. STRIJK, GOVERNMENT PRINTER AT 3.15 PM

WORKERS’ COMPENSATION AND

REHABILITATION ACT 1981

_________

WORKERS’

COMPENSATION AND
REHABILITATION
AMENDMENT
REGULATIONS 1999

1530 GOVERNMENT GAZETTE, WA [13 April 1999
13 April 1999] GOVERNMENT GAZETTE, WA 1531

Workers’ Compensation and Rehabilitation Act 1981

Workers’ Compensation and
Rehabilitation Amendment Regulations

1999

Made by the Governor in Executive Council.

1.             Citation

These regulations may be cited as the Workers’ Compensation and Rehabilitation Amendment Regulations 1999.

2.             Commencement

These regulations come into operation on 3 May 1999.

3.             The regulations amended

The amendments in these regulations are to the Workers’
Compensation and Rehabilitation Regulations 1982*.
[* Reprinted as at 14 February 1995.

For amendments to 11 March 1999 see 1997 Index to
Legislation of Western Australia, Table 4, p. 312, and Gazette
12 June 1998.]

4.             Regulation 6AA amended

(1) Regulation 6AA is amended by inserting before “Form 2B or”
the subregulation designation “(1)”.
(2) At the end of regulation 6AA the following subregulation is
inserted —

“

(2) In addition to the details prescribed in Form 2B as
being necessary to make a valid claim for
compensation under section 84I(1)(b) —

(a)

the “Injured worker’s declaration” and the “Consent authority”; and

1532 GOVERNMENT GAZETTE, WA [13 April 1999
(b) the tear-off attachments headed “DETAILS TO WORKER”,
BE PROVIDED TO MEDICAL
PRACTITIONER” and “INFORMATION TO

are prescribed under section 176(1)(a) as expedient for
the purposes of the Act, and are to be completed and

given to the appropriate parties accordingly.

”.

5.             Regulation 6A amended

(1) Regulation 6A is amended by inserting before “Form 3 in” the
subregulation designation “(1)”.
(2) At the end of regulation 6A the following subregulation is
inserted —

“

(2) In addition to the details prescribed in Form 3 as being
necessary to make a valid claim for compensation
under sections 57A and 57B, the “Consent Authority”
is prescribed under section 176(1)(a) as expedient for
the purposes of the Act, and is to be completed
accordingly.

”.

6.             Regulation 7 amended

Regulation 7(1) is amended by deleting the full stop after
“Appendix I” and inserting instead —
“

, or in the form of Form 3 in Appendix I if that form
has been marked to indicate that it is to be regarded as

both a first and final medical certificate.

”.

7.             Regulation 8 replaced

Regulation 8 is repealed and the following regulation is inserted instead —

“

8.             Frequency and time of medical examinations (s. 66)

(1)

A worker who receives a First Medical Certificate (Form 3) under the Act which nominates a medical review of the worker within a period of 14 days from

the date the certificate is issued cannot be required,
under section 64 or 65 of the Act, to submit himself for
examination by a medical practitioner provided by the
employer before a period of one month has elapsed
from the date the certificate is issued.
13 April 1999] GOVERNMENT GAZETTE, WA 1533

(2)

A worker who receives a First Medical Certificate (Form 3) under the Act which does not nominate a medical review of the worker within a period of 14 days from the date the certificate is issued may be

required, under section 64 or 65 of the Act, to submit
himself for examination by a medical practitioner
provided by the employer at any time from the date the
certificate is issued.
(3) A worker who fails to attend a medical review,
nominated on a First Medical Certificate in accordance
with subregulation (1), may be required, under section
64 or 65 of the Act, to submit himself for examination
by a medical practitioner provided by the employer at
any time from the date of that non-attendance.
(4) An employer shall not require a worker to attend a
medical review or examination —
(a) more frequently than once every 2 weeks; or
(b) at any time other than during reasonable hours.

”.

8.             Appendix I, Form 2B replaced

Appendix I, Form 2B is deleted and the following form is inserted instead —

“

FORM 2B

[Regulation 6AA]

Workers’ Compensation and Rehabilitation Act 1981
[section 84I(1)(b)]
WORKERS’ COMPENSATION CLAIM FORM

Employer Details
(To be completed by employer after receipt from the worker)

Name of policy holder: …………….………………………………………...…………………………..……... …………………………………………………………………………………………………………..…….…

Address: …………………………………………………………………...…………………………..………... ……………………………………………………………………………………………………….….……….

Suburb/town: …………………………………………………………...………………………………………. …………………………………………………………Postcode: …...………………………….……………..

Trading name of employer: .........................................................……………………………........................…. (e.g. Browns Pharmacy; ……………………………………………………………………………..……… E.J.Imports) …………………………………………………………………………………..…

Address of worker’s usual ….………....................................................………………………………………...
workplace or base: ....................................................................................……………………………...
…………………………………………………………Postcode ……………………………………………...
Major activity of workplace: ...............................................................................………………………...…..…
(e.g.sheep or grain farming; ..............................................................................………………………………..
aluminium window screen ...............................................................................………………..……………...

manufacturing) ................................................................................................................................

Office Use only ANZSIC CODE -

Insurance Co. ………………………………………… Policy No. ……………………………………..……... WorkCover No. W C ……………………………….. Claim No……………………………………..……….

Insurer/Self Insurer to complete

EMPLOYER: Forward to your insurer within 3 full working days of receipt from the Worker

1534 GOVERNMENT GAZETTE, WA [13 April 1999

Injured worker details

Surname: Mr/Mrs/Miss/Ms............……………………………….......................................................................
Other names: ....................................................………………………………....................................................
Address: ...............................................................................................................………………………………
...................................................................................... Postcode: ……………………………………………..

Phone No.: ………………………

Date of birth: ……../……../…….. Age: ………… Sex Male/Female

If you have difficulty understanding English, what is your
preferred language?
…………………………………………………………….

Occupation (e.g. first class welder; accounts clerk) …………………………………………………………… Main tasks or duties performed? (e.g. welding of …………………………………………………………... high pressure steam pipes; recording and paying …………………………………………………………... accounts) …………………………………………………………...

At the time of the occurrence

were you working as a:

Full Time r F

— direct employee? r 1
— working director? r 2

Part Time r P

— contractor? r 3
— employee of contractor? r 4 r 5
— sub-contractor? ASCO
— other? r 6

Occurrence details

Day of occurrence: ……………………… Date: ……../……../…….. Time:........ am/pm

At what address did the occurrence occur? .....................………………………………....................................

..............................................................................................................................………………………………

When did you have to stop working? Date: …../……../…….. Time:........ am/pm

Were you - on duty?r 1- travelling between home and work?r 4

- on duty & in a road traffic - doing something else, if so what? r 5

r 2

accident? ………………………………………
- on a work break? r 3 ……………………………………….

What actually happened and what caused the occurrence?

Include: Mechanism
(i) what action was involved, e.g. fall, caught between, struck by moving object
....................................................................…………………………………………………...
...............................................................................................................……………………… Agency
(ii) what object/machine was involved, e.g. petrol fumes, wooden door frame
......................................................…………………………………………………………….
...............................................................................................................……………………… Nature
Describe:
(i) the most serious injury or disease caused by the occurrence, e.g. fracture, burn,
cut, abrasion Bodily
...............................................................................................................……………………… Location
(ii) bodily location of the injury or disease, e.g. upper arm, ankle, eye
..................................................................................................................................................
13 April 1999] GOVERNMENT GAZETTE, WA 1535

Occurrence report

Where did the occurrence occur? (e.g. store room, machinery shop)

…………………………………………………………………………………………………………………….

What were you doing at the time of the occurrence?

…………………………………………………………………………………………………………………….

What were the normal working hours for Starting Finishing
: am/pm : am/pm
that day? time time
When did you first report the occurrence? Date: / / Time: / /
To whom did you report the occurrence? Name / Title …………………………………………
If the occurrence was not reported immediately, state ………………………………………………………
the reason: ……………………………………………………….
Name and address of witness(es) to the occurrence: ………………………………………………………
……………………………………………………….
Medical attention/history – this event
1. When did you first seek medical attention? Date / / Time / / am/pm
2. If not immediately, state reason: ………………………………………………………
………………………………………………………
3. Was the part of the body affected or injured by this
occurrence healthy before the occurrence? If not, give ………………………………………………………
details: ………………………………………………………

Medical attention/history – similar or related previous events

4. Is the present injury or disability totally attributable

to this occurrence? If not, give details: ………………………………………………………
………………………………………………………
5. Give details of any similar injury or disability prior
to this occurrence:  ………………………………………………………
………………………………………………………
6. Name & address of usual medical practitioner, and
any person who has treated you for a similar ………………………………………………………
disability: ……………………………………………………….
Other or previous claims
1. Is compensation being claimed Yes/No If so, from whom? ……………………………………....
from any other source? ………………………………………

2. Give details of similar or related previous workers’ compensation claims

Name & address of employer Name of insurer Nature of injury, disease or other
(if known) claim
1536 GOVERNMENT GAZETTE, WA [13 April 1999

Injured worker’s declaration

I solemnly and sincerely declare that each and every answer above and the particulars contained herein or annexed hereto relating to myself and the occurrence are true both in substance and in fact to the best of my knowledge and belief. I take notice that, under the provisions of section 59(2) of the Workers’ Compensation and Rehabilitation Act 1981, I am required to notify my employer in writing within 7 days if I commence work with another employer after making a claim, or while receiving weekly payments of workers’ compensation.

Dated this ………………………. day of ……………………….….. Year …………….

Signature of worker ……………………………………. Signature of witness ……………………………...

Consent authority (to be signed at the option of the worker)

I authorize any doctor who treats me (whether named in this certificate or not) to discuss my medical condition, in relation to my claim for workers’ compensation and return to work options, with my employer and with their insurer.

Dated this ………………………. day of ……………………….….. Year …………….

Signature of worker ……………………………………. Signature of witness ……………………………...

IMPORTANT:

FAILURE TO PROVIDE YOUR SIGNATURE ON EITHER THE DECLARATION OR THE

AUTHORITY ABOVE MAY DELAY A DECISION BY YOUR EMPLOYER ON YOUR CLAIM.

Insurer/Self-insurer to complete Insurer/Self-insurer’s

Date Stamp

Estimated time off work —

- less than one day……………….r - 10-20 work days (inclusive)…...r
- 1-4 work days (inclusive)……...r - more than 20 work days……….r
- 5-9 work days (inclusive)……...r - fatality…………………………r
13 April 1999] GOVERNMENT GAZETTE, WA 1537

Front

Employer please complete

If the First Medical Certificate indicates the injured worker will be absent from the workplace for more than 3 working

days and/or is unable to return to normal duties please

complete the section overleaf and fax to the medical practitioner who provided the worker’s First Medical

Certificate within 2 working days.

% = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = =
Employer, please provide the information overleaf to the

injured worker.

1538 GOVERNMENT GAZETTE, WA [13 April 1999

Reverse

ATTENTION Dr.___________________________ Fax No. ____________________

DETAILS TO BE PROVIDED TO MEDICAL PRACTITIONER

Please complete all sections of this form

WORKER’S DETAILS

Name in full: …………………………………………………………………………………………………...… Address: ………………………………………………………………………………………………………..… Telephone: …………………………………….……….………….. Date of birth ……../…………./……….… Occupation: …..………………………………..…………………………………………………………………

INSURER’S DETAILS

Name of insurer: …………………………………………………….…………………………………………… Contact person: …………………………………………………….. Telephone: …...………………………….

EMPLOYER’S DETAILS

Trading name: ……………………………………………………………………………………………………. Address of worker’s usual workplace: …………………………………………………………………………... …………………………………………………………………………………………………………………….

ALTERNATIVE DUTIES FOR WORKER

Name of contact for liaison with medical practitioner: ………………………………………………………….. Role within organization: ………………………………………………………………………………………... Telephone: …………………………………………………………..…. Fax: …...……………………………..

r The above nominated contact is willing to discuss alternative duties and / or appropriate return-to-
work options with the medical practitioner.

This organization can provide alternative duties which are attached. r Yes r No This organization has a return-to-work / rehabilitation program for injured workers. r Yes r No

Signature ………………………………………….……………………………………… Date …/…../……….

% = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = =

INFORMATION TO BE PROVIDED TO THE INJURED WORKER

EMPLOYER please ensure this section is given to the injured worker.

Workers’ Compensation Information for Injured Worker

• WorkCover WA is the government authority that administers the workers’ compensation system in Western Australia. WorkCover WA is available as an independent third party to help answer your questions about how the workers’ compensation system works. Contact WorkCover WA’s Infoline if

you need any information about the system.

• You should be notified by your employer’s insurance company if your claim is accepted or not within three weeks of submitting your claim to your employer.
• You have the right to choose your doctor and vocational rehabilitation provider.
• Provide your employer with all medical certificates from your doctor as quickly as possible.
• Under section 59(2) of the Workers’ Compensation and Rehabilitation Act 1981 you must notify your employer in writing within 7 days if you commence work with another employer after making a claim, or while receiving weekly payments of workers’ compensation.
• Regular contact between you, your doctor and employer is important and will assist the overall management of your claim. Make sure your doctor gives you a WorkCover WA brochure. This outlines what you should know about the system.
• An injury management system is in place and it is important you understand your rights and responsibilities in relation to your return to work. Contact WorkCover WA's Infoline to find out more.
• WorkCover WA runs free information seminars aimed at helping you understand the workers' compensation system. Contact WorkCover WA to arrange your attendance.

)RUZRUNHUV FRPSHQVDWLRQLQIRUPDWLRQRUDVVLVWDQFHFRQWDFW

:RUN&RYHU:$ V,QIROLQH&RXQWU\FDOOHUV

”.

13 April 1999] GOVERNMENT GAZETTE, WA 1539

9.             Appendix I, Form 3 replaced

Appendix I, Form 3 is deleted and the following form is inserted instead —

“

FORM 3
Workers’ Compensation and Rehabilitation Act 1981

[sections 57A (1) (b), 57B (1) (b) & 61(1)] FIRST MEDICAL CERTIFICATE

1. Worker’s Details

r I have provided a WorkCover WA Injury Management brochure to the worker.

First name(s): ..................................……………............... Surname: ......……………...............…………….....
Address: .......................................................................................................……………………………………...
2. Employer Details
Name & address of worker’s employer: ..………………………………………………………………………..

.……………………………………………………………………………………………………………………

3. Consent Authority (to be signed at the option of the worker)

I authorize any doctor who treats me (whether named in this certificate or not) to discuss my medical condition, in relation to my claim for workers’ compensation and return to work options, with my employer and with their insurer.

Worker’s Signature ……………………………………… Date ………………

IMPORTANT: FAILURE TO PROVIDE YOUR SIGNATURE ON THE AUTHORITY ABOVE

MAY DELAY A DECISION BY YOUR EMPLOYER ON YOUR CLAIM.

AFFECTED AREA

4. Details from Worker Date of injury/disease, etc: ..………………..... Workplace location where incident occurred: ...………..…………………... Worker’s description of the injury/disease, etc: ...……...…………………... ………………………………………………………….……………………
Worker’s description of how it occurred: ..……..…….……………………. …..…………………………………………………………………………...

….……………………………………………………………………………

5. Medical Assessment
Clinical findings / diagnosis (include possible complications, effect of prior
injury or medical condition):

………………………………………………………………………………

………………………………………………………………………………

………………………………………………………………………………

………………………………………………………………………………

In my opinion the above diagnosis does r / does not r correlate with the
injury/disease, etc. described to me by the worker.
INJURY MANAGEMENT

6. Fitness for Work It is my opinion that as from the date of this certificate the worker is:
FIT

r Fit to return to pre-disability duties, no further treatment r First and Final certificate
required [See reg 7 and s. 61(1) of the Act]

r Fit to return to pre-disability duties, but requires further treatment
r Fit for restricted return to work from ………………………………… to ………………………………….
r restricted hours (please specify): ……...………………………………………………………….……
r restricted days (please specify): …..……………………………………………………………...……
r restricted duties.

1540 GOVERNMENT GAZETTE, WA [13 April 1999

r Work restrictions:

r No lifting anything heavier than …….. kg. Other restrictions: …………………………………..
r Avoid repetitive bending / lifting. ………………………………………………………
r Avoid repetitive use of body part: ………………………………………………………
r Avoid prolonged standing/ walking / sitting. ………………………………………………………
r Keep injured area clean and dry. ………………………………………………………

UNFIT

r Totally unfit for work for …………… days from ………….. to …………………. (inclusive).

7. Medical Management
r Medication: ………………………………………………………………………………………………….
r Physiotherapy / Chiropractor No. sessions recommended: ……………r Imaging …………………...…
r Referred to hospital/specialist (name) …………………………………………………………………..…
Other treatment: ..………………………………………………………………………………………………...

…………………………………………………………………………………………………………….………

…………………………………………………………………………………………………………………….

Next appointment (unless “First & Final Certificate”) Date …..………… Time ……………….………...

If the worker is not reviewed within 14 days, the worker may be required, under section 64 or 65 of the Act, to submit to a medical examination by a medical practitioner provided by

the employer, on a day chosen by the employer.

8. Medical Practitioner / Employer Contact
r I have made contact with the employer and discussed alternative work options.

r The worker will be off work for more than 3 working days and/or is unable to return to normal duties.

Employer please fax your contact details as I will contact you to discuss return to work options.

r The worker is able to return to normal duties. Contact with employer not necessary at this stage.

9. Medical Practitioner’s Details
Name ………………………………………….. Registration No. ………………………………………………
Address……………………………………………………………………………………………………………
Telephone ……………………………………... Signature ……………………………………………………...

Fax …………………………………………….. Time & Date of examination …………………………………

)RUZRUNHUV FRPSHQVDWLRQLQIRUPDWLRQRUDVVLVWDQFHFRQWDFW

:RUN&RYHU:$ V,QIROLQH&RXQWU\FDOOHUV

”.

10.           Appendix I, Form 3A amended

Appendix I, Form 3A is amended as follows:

(a)

by deleting “Claim number:” and inserting instead — “ *Claim number: ”;

(b) by inserting at the base of the Form the following —

“

* Please provide this claim number to your general practitioner at

your next appointment in relation to this claim.

”.

11.           Appendix I, Form 4 replaced

Appendix I, Form 4 is deleted and the following form is inserted instead —

13 April 1999] GOVERNMENT GAZETTE, WA 1541

“

FORM 4
Workers’ Compensation and Rehabilitation Act 1981
[section 61(1)]
FINAL MEDICAL CERTIFICATE

Claim No. (if known)

To (name and address of worker’s employer)

.………………………........................................................................................................................

..........................................................………………………………...................................................

WORKER’S DETAILS

First name(s): …………………………………………. Surname: ………………………………… Address: …………………………………………………………………………………………….. Telephone: ………………………………………………………………………………………….. Date and place of occurrence of disability: …. / …. / ……. ……………………………………….

MEDICAL ASSESSMENT

Having examined the worker, it is my opinion that as from ….. / …… / ………….
r the worker has wholly recovered from the effects of the disability.
r the worker has partially recovered from the effects of the disability.

r the worker's incapacity is no longer a result of the disability.

It is also my opinion that as from ….. / …… / …………. the worker is
r fit.
r fit for alternative duties with the following limitations:
...............…….........……………………….........................................................................................
.....................……………………………............................................................................................
...............................................................……………………………..................................................

.........................................................................................................……………………………........

Grounds for the opinion in medical assessment
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
.............................................................................................................................................................
.......…………………………………………………………………………………………………..

1542 GOVERNMENT GAZETTE, WA [13 April 1999
13 April 1999] GOVERNMENT GAZETTE, WA 1543
1544 GOVERNMENT GAZETTE, WA [13 April 1999

MEDICAL PRACTITIONER'S DETAILS

Name: ………………………………………… Registration No.: ..……………………………….. Address: …...………………………………………………………………………………………... Telephone …………………………………….

Fax ……………………………………………

Signature ……………………………………. Time & Date of examination: ..……………………

)RUZRUNHUV FRPSHQVDWLRQLQIRUPDWLRQRUDVVLVWDQFHFRQWDFW

:RUN&RYHU:$ V,QIROLQH&RXQWU\FDOOHUV

”.

By Command of the Governor,

M. C. WAUCHOPE, Clerk of the Executive Council.

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