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
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
Date of lodgement