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