A. Patient and employer details Mandatory
Family name:
Claim number (if known):
Date of birth:
B. Injury details and assessment Mandatory
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):
Is this a new injury/condition?
My clinical diagnosis/es based on my examination of you and other available information is:
Other comments/clinical ndings:
C. Certication Mandatory
In my opinion, you: (please tick whichever apply)
have recovered from your injury/condition and are t to return to your normal duties and hours on:
are t to perform suitable duties that accommodate your functional abilities from:
are medically unt to undertake suitable duties while recovering from your injury for the period:
Note: Certication based on your functional ability, not available duties.
weeks OR
uncertain at this stage
I estimate you should have functional capacity to return to work in days
(estimated timeframe will assist with planning for return to safe work)
I would like to review your progress on:
at your next medical consultation
D. Treatment plan Complete all elds relevant to your patient
The following treatment plan is aimed at assisting your recovery and return to work:
I have referred you for the following clinical treatment:
Medical specialist (Name & specialty)
Psychologist (Name)
Physiotherapist (Name)
Other (Name & discipline)
Work Capacity Certificate
Version 2 effective 1 July 2017
Given names:
Employer name:
Yeses No
Yeses No
OFFICIAL: Sensitive//Medical in Confidence
E. Functional ability Complete all elds relevant to your patient
Your ability to work is aected by this injury(s)/condition(s) as follows:
(please select applicable functions – blank elds indicate that limitations don’t apply. Please include any impact of medications on function)
No restrictions - go to section G (Doctor’s details)
Physical function
Can Withmodications Cannot
Reaching above shoulder:
Use of aected body part:
Neck movement:
Climbing steps/stairs/ladders:
Mental health function Notaected Partiallyaected Aected
Memory (short term and/or long term):
Judgement (ability to make decisions):
Other functional considerations - not listed above
I have prescribed medication(s) that could impact upon your ability to undertake some activities.
I recommend:
A graduated increase in working hours over weeks from hours a day to your normal hours/ hours a day
Non-consecutive working days for a period of days or weeks
F. Communication Optional
Preferred contact method: phone email fax writing visit
G. Doctors details Mandatory
Doctor’s name:
Comments (e.g. details of capacity or limitations that will assist
in identication of suitable duties)
Provider Number:
Email address:
Completion date: