OFFICIAL: Sensitive
Pre-injury Employer Service
Durable return to work certificate
Claim and referral details
Worker name
Date of Birth
Claim Number Claims Agent
Employer
Date of Referral Closure Date
Outcome
Outcome Eligibility
☐ A return to suitable duties at full pre-injury hours has been achieved and sustained for 13 consecutive weeks:
Start date: End date:
Worker receives or is due to receive equal to or less than 5%
of their maximum income support entitlement throughout
the durability period.
Income Support
Income support at referral $ per week
Income support during durability period $ per week
Outcome Requested
☐ WR360 (achieved in Level 1 or invoiced less than 10 hours in Level 2)
☐ WR361 (hours invoiced between 11 – 15 hours in Level 2)
☐ WR362 hours invoiced between 16 -20 hours in Level 2)
Evidence of Outcome Achieved (to be attached)
☐ Worker Payslip/s ☐ Employer Payslip/s
☐ Written confirmation from Worker ☐ Written confirmation from Employer
☐ Other – Please describe
if no evidence can be obtained, please complete the following;
☐ I certify that all reasonable effort has been made to obtain the supporting evidence without success
Provider details
Consultant Name:
Provider Provider number
Phone number Email
Date completed
Date of lodgement
