Work and Injury Management Plans

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GUIDELINES FOR ALL INSURERS & EMPLOYERSIncapacityIncapacity may be total, partial or a combination of both. Where a worker is unfit for an initial period ofbetween 5 days and 28 days, but continues to be certified unfit to the point where 28 days or more isreached, then it will be necessary to prepare a RTW Plan followed by an IM Plan.Guidelines for Meeting the RequirementsThe following template is to be used as a guide only for preparing Return to Work Plans and InjuryManagement Plans. Plans are to be tailored to the worker to ensure that their specific needs are met.This information is for guidance only and is not to be taken as an expression of the law. It should be read in conjunction with theWorkers Rehabilitation and Compensation Act 1988 and any other relevant legislation.
GUIDELINES FOR ALL INSURERS & EMPLOYERSRETURN TO WORK PLAN/INJURY MANAGEMENT PLANType of Plan Return to Work (RTW) Plan Injury Management (IM) PlanCONTACT DETAILS:Worker’s NameClaim NumberWorker’s Contact Numbers M HWorker’s Supervisor/Return to Work Co-ordinatorContact Number M WE-mailName of Primary Treating Medical PractitionerContact Number M WE-mailName of Injury Management Co-ordinatorContact Number M WE-mailWORKER’S EMPLOYMENT DETAILS:Worker’s Work LocationWorker’s Pre-injury PositionWorker’s Pre-injury Hours/DaysMEDICAL ASSESSMENT:Date of Injury…../……/…….…Date of Assessment …../……/…….…DiagnosisCAPACITY TO WORK:Is the worker:Requiring treatment but fit for pre-injury dutiesFit for suitable dutiesIncapacitated for any workCertificate dates:From ……/……/.……….. To ……/……/.………..From ……/……/.……….. To ……/……/.………..From ……/……/.……….. To ……/……/.………..RETURN TO WORK:Is the worker currently participating in a RTW Plan or IM Plan? No YesIf yes, specify type of plan RTW Plan IM PlanDutiesIf the worker is fit, are they returning to:Full dutiesPartial duties If partial, are duties graduated? If yes, detail below:Hours/DayDays/WeekWeek to Week Week to WeekRest breaksAre rest breaks required?No Yes If yes minutes every hour(s)Areas of reduced capacityRestrictions (including specific medical):This information is for guidance only and is not to be taken as an expression of the law. It should be read in conjunction withWorkers Rehabilitation and Compensation Act 1988 and any other relevant legislation.the
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Work and Injury Management Plans

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