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4. Certification
• 14 days for the first certificate (must be issued by a medical practitioner), • 28 days for a subsequent certificate.
Taking into account the effects of your injury/condition, as outlined in section 3, you:
Have a capacity for pre-injury employment from / /
Have a capacity for suitable employment from / / to / /
Have no capacity for employment from / / to / /
Estimated timeframe to return to work days or weeks
An estimated timeframe will assist with planning for a return to safe work
5. Treatment Plan
Your treatment plan including injury management, strategies to increase capacity for work, address return to work barriers and/or prevent
recurrence/aggravation of injury:
6. Certifier Declaration
I certify that I have clinically examined this patient. The information and medical opinions I have provided in this certificate are,
to the best of my knowledge, true and correct.
Provider name, address and phone no. (or practice stamp)
Postcode
Telephone ( )
Signature of Certifier
Provider number or hospital name
Date issued
/ /
7. Worker Declaration – WORKER TO COMPLETE
MANDATORY unless this is the first certificate or an attendance certificate only
At any time since the last Certificate of Capacity was provided, have you engaged in:
– voluntary work, or
– any form of employment or in self-employment for which you have received or been entitled to receive payment in money or otherwise?
No, I have not
Yes, I have
Please provide details of any voluntary work, employment or self-employment you have engaged in (other than with your pre-injury
employer as part of your return to work):
I declare that the details I have given on this certificate are true and correct. I understand that it is an offence under the legislation
to provide false or misleading information.
Signature
of Worker
Date / /
Further Information
Returning to work
If you have a work capacity for suitable employment your employer and case
manager will use the information provided by your certifier on the Certificate of
Capacity to assess suitable options for you to safely stay at or return to work. They
will take into account what you can do safely and any limitations that apply to your
individual circumstances. A capacity for suitable employment could mean working
reduced hours while you recover or working modified or different duties until you
can return to your normal work with your pre-injury employer or another employer.
Privacy
FOR844/03/07.15
Note: Certificate durations for a work-related injury/condition (WorkSafe claim), unless special reasons apply are up to:
The TAC and WorkSafe (WorkSafe Agents and Self-Insurers) will handle your personal
and health information in accordance with their privacy policies and legislation.
You can access privacy policy information at the TAC and WorkSafe websites.
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