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Insurer
Postal Address
Name
Contact No.
Direct Email
Central Email
Preferred Consultant (if known)
Email
Date of birth
Address
Disability
Date of disability
Date last worked
Pre-disability occupation
Work status
Policy/Claim No.
Policy Type
IPGSCTPD
Doctor details
Email/Fax
Is medical approval required? YesNo
Commencement of RTWSuitability of RTW and/or vocational optionsJob unattached RTW support (job-seeking)Participation in a functional upgrade programOther: (Free text)
Employer
Date of referral
Reason for referral
Support Provision - select one
Pre-vocational capacity buildingJob attached RTW supportJob unattached RTW support (job-seeking)Single assessment onlyTPD Single Service
Service option
Exercise physiology – Wellbeing serviceExercise physiology – Work readinessExercise physiology – RTW supportWellbeing service – Functional upgrading service
Service goal
Customer demonstrates improved functional capacity for daily activities and/or work
Status options
1. Exercise program – limited functional capacity1. Exercise program – little /no change in functional capacity2. Exercise program – increased functional abilities but no RTW capacity3. Exercise program – can participate in RTW
Customer demonstrates physical capacity for performing full pre-disability role
1. Exercise program – limited functional capacity1. Exercise program – little /no change in functional capacity2. Exercise program – customer demonstrates capacity for 25% of pre-disability duties3. Exercise program – customer demonstrates capacity 50% of pre-disability duties4. Exercise program – customer demonstrates capacity 75% of pre-disability duties5. Exercise program – customer demonstrates full capacity for pre-disability duties
Pre-dis occupation / Pre-dis employer / Partial RTWPre-dis occupation / Pre-dis employer / Full RTW
1. Exercise program – limited functional capacity1. Exercise program – little /no change in functional capacity2. Exercise program – increased functional abilities but no RTW capacity2. No RTW – Medical approval for RTW or of RTW Plan3. Pre-dis employer / Partial hrs / Modified or alternative duties4. Pre-dis employer / Partial hrs / Full duties5. Pre-dis employer / Full hrs / Modified or alternative duties6. Pre-dis employer / Full hrs / Full duties
1. Exercise program – limited functional capacity1. Exercise program – limited functional capacity1. Exercise program – little /no change in functional capacity2. Exercise program – increased functional abilities but no RTW capacity2. No RTW – Medical approval for RTW or of RTW Plan3. Pre-dis employer / Partial hrs / Modified or alternative duties4. Pre-dis employer / Partial hrs / Full duties
Customer demonstrates improved wellbeing and functional capacity for daily activities and/or work
1. Wellbeing services – limited functional capacity1. Wellbeing services – little /no change in wellbeing2. Wellbeing service – demonstrated improvement in wellbeing but no RTW capacity3. Wellbeing service – can participate in RTW
Pre-disability employment RTW support
Pre-dis occupation / Pre-dis employer / Full RTWPre-dis occupation / Pre-dis employer / Partial RTWAlternate occupation / Pre-dis employer / Full RTWAlternate occupation / Pre-dis employer / Partial RTW
1. No RTW – medical barriers1. No RTW – other barriers2. No RTW – Medical approval for RTW or of RTW Plan3. Pre-dis employer / Partial hrs / Modified or alternative duties4. Pre-dis employer / Partial hrs / Full duties5. Pre-dis employer / Full hrs / Modified or alternative duties6. Pre-dis employer / Full hrs / Full duties
1. No RTW – medical barriers1. No RTW – other barriers2. No RTW – Medical approval for RTW or of RTW Plan3. Pre-dis employer / Partial hrs / Modified or alternative duties4. Pre-dis employer / Partial hrs / Full duties
1. No RTW – medical barriers1. No RTW – other barriers2. No RTW – Medical approval for RTW or of RTW Plan3. Pre-dis employer / Partial hrs / Modified or alternative duties4. Pre-dis employer / Full hrs / Modified or alternative duties
1. No RTW – medical barriers1. No RTW – other barriers2. No RTW – Medical approval for RTW or of RTW Plan3. Pre-dis employer / Partial hrs / Modified or alternative duties
Vocational counsellingIndependent job-seeker training programJob-seeking support
Identification of medically approved vocational options
1. No suitable vocational options for RTW identified2. Identification of vocational options – not medically approved3. Identification of vocational options – medically approved (to progress to job-seeking)
Customer demonstrates ability to independently job-seek
1. Customer has no job-seeking skills2. Customer partially demonstrating skills and resources for independent job-seeking3. Customer demonstrating ability to independently job-seek
Pre-dis occupation / Alternative employer / Full RTWPre-dis occupation / Alternative employer / Partial RTW
1. No RTW – medical barriers1. No RTW – other barriers2. Identification of vocational options – not medically approved3. Identification of vocational options – medically approved (to progress to job-seeking)4. Customer partially demonstrating skills and resources for independent job-seeking5. Customer demonstrating ability to independently job-seek6. Customer participating in work trial7. Alternative employer / Partial hrs / Modified or alternative duties8. Alternative employer / Partial hrs / Pre-disability duties9. Alternative employer / Full hrs / Modified or alternative duties10. Alternative employer / Full hrs / Pre-disability duties
1. No RTW – medical barriers1. No RTW – other barriers2. Identification of vocational options – not medically approved3. Identification of vocational options – medically approved (to progress to job-seeking)4. Customer partially demonstrating skills and resources for independent job-seeking5. Customer demonstrating ability to independently job-seek6. Customer participating in work trial7. Alternative employer / Partial hrs / Modified or alternative duties8. Alternative employer / Partial hrs / Pre-disability duties
Initial Needs AssessmentWorkplace AssessmentErgonomic AssessmentVocational AssessmentTask Analysis (IP/GSC)Transferrable Skills Assessment (IP/GSC)Business Viability AssessmentFunctional Capacity Evaluation
Appropriate completion of Initial Needs Assessment
1. Assessment referred (not commenced)
Appropriate completion of Workplace Assessment
2. Assessment in progress
Appropriate completion of Ergonomic Assessment
3. Assessment completed
Appropriate completion of Vocational Assessment
3. Supplementary/amendment assessment completed
Appropriate completion of Task Analysis
Appropriate completion of Transferrable Skills Assessment
Appropriate completion of Business Viability Assessment
Appropriate completion of Functional Capacity Evaluation
Employability AssessmentTransferrable Skills AssessmentTask AnalysisADL Assessment
Appropriate completion of Employability Assessment
Appropriate completion of ADL Assessment
Background to claim
Specific issues/questions to be addressed in your report
Attachments - upload file
6 hours
1 hour
4.5 hours – standard report
6 hours - If report is to include background information (symptoms, function, treatment, treater contact)
1 hour per new plan (not a revision)
6 hours for base report
8 hours - If report is to include an in depth labour market
5 hours
3 hours
10 hours for desk-based assessment
12 hours for telehealth or in- person interview
12 hours – including labour market research including labour market contacts
7 hours – including Set up and interview (with customer or another business)
7 hours for PADLs
8 hours for Home duties
3.5 hours
*(Hourly rate calculated at $231.44 INC GST)
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