Fillable Job Placement Services (ReturnToWorkSA)

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Job Placement Services (ReturnToWorkSA)

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The Job Placement Services (ReturnToWorkSA) form is 2 pages long and contains:

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Country of origin: AUSTRALIA
File type: PDF

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S
ensitive: Personal
Job Placement Services
Outcome report – employment placement fee
Claim and referral details
Worker name Claim number
Claims agent Notional weekly earnings
Case manager Pre injury hours
JPS provider Employment consultant
Employment placement information
New employer details
Business name Placement start date
Contact person Position title
Address Earnings (per week)
Phone/fax Hours & days of employment
(per week)
Email Employment status ☐ Permanent
☐ Full-time
☐ Casual
☐ Part-time
Placement start date Two weeks end date
Summary of service and supports provided Please describe
Evidence of placement income
☐ Payslip ☐ Employment contract ☐ Employer document ☐ Other
Please describe
Agreed Post Placement Support Please describe
Placement fee requested
☐ JB401 ☐ JB402
Certified medical capacity at placement (per week) – as per medical certificate dated: Hours:
Hours of work per week in paid employment = per week
Provider details
Consultant Company
Phone Email
Address
Signature
Date of lodgement
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Job Placement Services (ReturnToWorkSA)

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Completed 29 July 2021

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