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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  • 14 check-boxes
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Country of origin: AUSTRALIA
File type: PDF

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OFFICIAL: Sensitive
Job Placement Services
Outcome report – 26 week durability fee
Claim and referral details
Worker name
Date of Birth Claim Number
Claims Agent Claims Manager
JPS provider Date of Referral
Placement fee requested
Outcome Requested
☐ JB460 – at or above Notional Weekly Earnings
☐ JB462 – at or above Full Pre-Injury Hours
☐ JB464 – less than Notional Weekly Earnings
☐ JB466 – less than Full Pre-Injury Hours
Evidence of income, hours and durable placement (attached)
☐ Payslip ☐ Employment contract ☐ Employer document ☐ Other
Please describe
Durability information
Placement Start Date: 26 working weeks end date:
Re-anchoring (where relevant)
Start date: End date (max 10 days):
Previous payments (where relevant)
Have there been one or more 26-week durability fee
claimed per job placement for this worker?
☐ Yes ☐ No
If you have answered YES, you are not eligible to claim the 26-week
durability fee
Average Weekly Earnings (Enter values from JPS Eligibility Calculator)
Cumulative salary paid from week 14 to 26 during durable placement $
Cumulative 13 weeks’ average weekly earnings $
Percentage of average weekly earnings %
Working Hours
Pre Injury Hours per week
Current hour per week per week
OFFICIAL: Sensitive
Employment information
Role Information
Position Title
Employment status ☐ Permanent ☐ Full-time ☐ Part-time ☐ Casual
Hours & days (per week)
Employer details
Business Name
ABN / ACN
Address
Contact person
Contact Number / Email
Service Provision
Summary of service and supports provided Please describe
Details regarding placement (e.g. worker’s status in return to work, any risks to durability) Please describe
Provider details
Consultant Name:
Provider Provider number
Phone number Email
Date completed
Date of lodgement
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Job Placement Services (ReturnToWorkSA)

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Completed 29 July 2021

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