OFFICIAL: Sensitive
Job Placement Services
Outcome report – 13 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
JB450 – at or above Notional Weekly Earnings
JB452 – at or above Full Pre-Injury Hours
JB454 – less than Notional Weekly Earnings
JB456 – 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: 13 working weeks end date:
Re-anchoring (where relevant)
Start date: End date (max 10 days):
Previous payments (where relevant)
Have there been more than two 13-week durability
fees in past 12 calendar months?
☐ Yes ☐ No
If you have answered YES, you are not eligible to claim the 13-week
durability fee
Average Weekly Earnings (Enter values from JPS Eligibility Calculator)
Cumulative 13 weeks’ salary paid 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
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
Agreed Post Placement Support Please describe
Provider details
Consultant Name:
Provider Provider number
Phone number Email
Date completed
Date of lodgement