A. Patient and employer details
Family name:
Claim number (if known):
Date of birth:
B. Injury details and assessment
I examined you on: for injury(s)/condition(s) you stated occurred/developed on:
The stated cause was:
The injury(s)/condition(s) you presented with is/are consistent with your stated cause(s)
Yes No
My clinical diagnosis/es based on my examination of you and other available information is:
Other comments/clinical findings:
C. Certification (for a maximum period of 7 days)
In my opinion, you: (please tick whichever apply)
have recovered from your injury/condition and are fit to return to your normal duties and hours on:
some further treatment may be required
are fit to perform suitable duties that accommodate your functional abilities from: to
are medically unfit to undertake suitable duties while recovering from your injury for days (up to and including a maximum of 7 days).
Note: Certification based on functional capacity, not available duties.
Reason:
Comments:
D. Nurse Practitioner’s details
Nurse Practitioner’s name:
Address:
Provider Number:
Emergency Department
Nurse Practitioner Work Capacity Certicate
Please attend a Ge
neral Practitioner for ongoing treatment and certification.
Given names:
Employer name:
Signed:
Completion date:
OFFICIAL: Sensitive//Medical in Confidence
