OFFICIAL: Sensitive
Fit for Work (FFW) Service
Intervention outcome report
Claim and referral details
Worker name
Date of Birth Date of Injury
Claim Number Claims Agent
Date of Referral Closure Date
Fitness Upgrade Program
Start date (DD/MM/YYYY) End date (DD/MM/YYYY)
Fitness pathway service (list) Contribution to worker’s certified medical capacity
OFFICIAL: Sensitive
Certified Capacity
Pre Injury Hours hours per week
Current hour per week hours per week
Outcome Requested
☐ FW242 - No increase in capacity
☐ FW246 - Certified for less than pre-injury hours
☐ FW248 - Certified for full pre-injury hours
Evidence of Outcome Achieved (to be attached)
☐ Work Capacity Certificate (mandatory) ☐ Medical evidence ☐ Other
Please provide details
Considerations and Recommendations
Considerations which may impact ability to maintain capacity Please provide details
Recommendations to consider to gain and/or maintain suitable employment Please provide details
Provider details
Consultant Name:
Provider Provider number
Phone number Email
Date completed
Date of lodgement