Easec Occupational Health

Referrer Details

Insurer Details

Insurer

Postal Address

Recovery Specialist Details

Name

Contact No.

Direct Email

Central Email

Service Provider Details

Preferred Consultant (if known)

Email

Contact No.

Insured Details

Insured

Name

Date of birth

Address

Contact No.

Email

Disability

Date of disability

Date last worked

Pre-disability occupation

Work status

Policy Details

Policy/Claim No.

Policy Type

IPGSCTPD

Other Contact Details

Doctor details

Address

Contact No.

Email/Fax

Is medical approval required? YesNo

[group MedicalApprovalYes]

Commencement of RTWSuitability of RTW and/or vocational optionsJob unattached RTW support (job-seeking)Participation in a functional upgrade programOther: (Free text)

[group OtherFreeText]

[/group] [/group]

Employer Details

Employer

Address

Contact No.

Email/Fax

Referral Details

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

[group ServiceOptionPre]

Service option

Exercise physiology – Wellbeing serviceExercise physiology – Work readinessExercise physiology – RTW supportWellbeing service – Functional upgrading service

[group CustomerDemonstratesImproveds]

Service goal

Customer demonstrates improved functional capacity for daily activities and/or work

[group ExerciseProgramImproveds]

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

[/group] [/group] [group CustomerDemonstratesPhysicals]

Service goal

Customer demonstrates physical capacity for performing full pre-disability role

[group ExerciseProgramPhysicals]

Status options

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

[/group] [/group] [group CustomerDemonstratesOccupations]

Service goal

Pre-dis occupation / Pre-dis employer / Partial RTWPre-dis occupation / Pre-dis employer / Full RTW

[group ExerciseProgramOccupations]

Status options

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

[/group] [group ExerciseProgramPres]

Status options

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

[/group] [/group] [group CustomerDemonstratesCapacitys]

Service goal

Customer demonstrates improved wellbeing and functional capacity for daily activities and/or work

[group ExerciseProgramCapacitys]

Status options

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

[/group] [/group] [/group] [group ServiceOptionJobs]

Service option

Pre-disability employment RTW support

[group CustomerJobFulls]

Service goal

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

[group ExerciseProgramJobFulls]

Status options

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

[/group] [group ExerciseProgramJobPartials]

Status options

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

[/group] [group ExerciseProgramJobAlternateFulls]

Status options

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

[/group] [group ExerciseProgramJobAlternatePartials]

Status options

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

[/group] [/group] [/group] [group ServiceOptionJobUnattacheds]

Service option

Vocational counsellingIndependent job-seeker training programJob-seeking support

[group CustomerUnattachedIdentifications]

Service goal

Identification of medically approved vocational options

[group ExerciseUnattachedIdentifications]

Status 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)

[/group] [/group] [group CustomerUnattachedSeeks]

Service goal

Customer demonstrates ability to independently job-seek

[group ExerciseUnattachedSeeks]

Status options

1. Customer has no job-seeking skills2. Customer partially demonstrating skills and resources for independent job-seeking3. Customer demonstrating ability to independently job-seek

[/group] [/group] [group CustomerUnattachedSupports]

Service goal

Pre-dis occupation / Alternative employer / Full RTWPre-dis occupation / Alternative employer / Partial RTW

[group ExerciseUnattachedFulls] [/group] [group ExerciseUnattachedPartials]

Status options

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

[/group] [/group] [/group] [group ServiceOptionSingles]

Service option

Initial Needs AssessmentWorkplace AssessmentErgonomic AssessmentVocational AssessmentTask Analysis (IP/GSC)Transferrable Skills Assessment (IP/GSC)Business Viability AssessmentFunctional Capacity Evaluation

[group ExerciseSingleInitials]

Service goal

Appropriate completion of Initial Needs Assessment

[group ExerciseSingleInitialAssessments]

Status options

1. Assessment referred (not commenced)

[/group] [/group] [group ExerciseSingleWorkplaces]

Service goal

Appropriate completion of Workplace Assessment

[group ExerciseSingleWorkplaceAssessments]

Status options

2. Assessment in progress

[/group] [/group] [group ExerciseSingleErgonomics]

Service goal

Appropriate completion of Ergonomic Assessment

[group ExerciseSingleErgonomicAssessments]

Status options

3. Assessment completed

[/group] [/group] [group ExerciseSingleVocationals]

Service goal

Appropriate completion of Vocational Assessment

[group ExerciseSingleVocationalAssessments]

Status options

3. Supplementary/amendment assessment completed

[/group] [/group] [group ExerciseSingleTasks]

Service goal

Appropriate completion of Task Analysis

[/group] [group ExerciseSingleTransferrables]

Service goal

Appropriate completion of Transferrable Skills Assessment

[/group] [group ExerciseSingleViabilitys]

Service goal

Appropriate completion of Business Viability Assessment

[/group] [group ExerciseSingleFunctionals]

Service goal

Appropriate completion of Functional Capacity Evaluation

[/group] [/group] [/group] [group ServiceOptionTPDs]

Service option

Employability AssessmentTransferrable Skills AssessmentTask AnalysisADL Assessment

[group ExerciseTPDs]

Service goal

Appropriate completion of Employability Assessment

[group ExerciseTPDEmployabilitys]

Status options

1. Assessment referred (not commenced)

[/group] [/group] [group ExerciseSkills]

Service goal

Appropriate completion of Transferrable Skills Assessment

[group ExerciseSkillsEmployabilitys]

Status options

2. Assessment in progress

[/group] [/group] [group ExerciseCompleteds]

Service goal

Appropriate completion of Task Analysis

[group ExerciseCompletedsEmployabilitys]

Status options

3. Assessment completed

[/group] [/group] [group ExerciseADLs]

Service goal

Appropriate completion of ADL Assessment

[group ExerciseADLsEmployabilitys]

Status options

3. Supplementary/amendment assessment completed

[/group] [/group] [/group]

Background to claim

Specific issues/questions to be addressed in your report

Attachments - upload file

Services Requested (Enter total hours approved in relevant boxes below)

*(Travel funding not included)

Initial Needs Assessment

6 hours

Medical case conference

1 hour

Workplace Assessment

4.5 hours – standard report

6 hours - If report is to include background information (symptoms, function, treatment, treater contact)

Development of graded Return to Work Plan

1 hour per new plan (not a revision)

Vocational Assessment

6 hours for base report

8 hours - If report is to include an in depth labour market

Vocational counselling

5 hours

Ergonomic Assessment

3 hours

Functional Capacity Evaluation

5 hours

Employability Assessment (TPD)

10 hours for desk-based assessment

12 hours for telehealth or in- person interview

Transferable Skills Assessment (TPD)

6 hours

12 hours – including labour market research including labour market contacts

Comparative Task Analysis

6 hours

7 hours – including Set up and interview (with customer or another business)

ADL Assessment (TPD)

7 hours for PADLs

8 hours for Home duties

Exercise Physiology Initial Assessment

3.5 hours

Travel Hours Approved

Additional Funding (Hours) Approved

TOTAL SERVICE HOURS

TOTAL APPROVED FEES

*(Hourly rate calculated at $231.44 INC GST)

Referrer Details

Insurer Details

Recovery Specialist Details

Service Provider Details

Insured Details

Insured

Policy Details

Other Contact Details

Employer Details

Referral Details

Services Requested (Enter total hours approved in relevant boxes below)

*(Travel funding not included)

Initial Needs Assessment

Medical case conference

Workplace Assessment

Development of graded Return to Work Plan

Vocational Assessment

Vocational counselling

Ergonomic Assessment

Functional Capacity Evaluation

Employability Assessment (TPD)

Transferable Skills Assessment (TPD)

Comparative Task Analysis

ADL Assessment (TPD)

Exercise Physiology Initial Assessment

Travel Hours Approved

Additional Funding (Hours) Approved

TOTAL SERVICE HOURS

TOTAL APPROVED FEES

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