Injured worker details Plan details Worker Goal – long term: …… Claim number Plan completed by: Employer/Provider/Insurer Phone Objective of this plan: …… Supervisor Duration of this plan …… Phone From: To: …… …… …… Treating medical practitioner Fit for suitable duties (restricted return to work) .. From: To: …… …… Phone Job description: …… …… Task details Week Duties Restrictions …… …… Week 1 commencing: – …… Days: …… Hours: …… …… …… Week 2 commencing: – …… Days: …… Hours: …… …… …… Week 3 commencing: – …… Days: …… Hours: …… …… …… Week 4 commencing: – …… Days: …… Hours: …… Treatment occurring during this plan (e.g. physiotherapy): Training required: Yes No by: …… If ‘Yes’, given …… Plan to be reviewed on: Training given on: …… …… Signatures Treating medical practitioner Worker
Injured worker details Plan details Worker Goal – long term: …… Claim number Plan completed by: Employer/Provider/Insurer Phone Objective of this plan: …… Supervisor …… Duration of this plan Phone …… From: …… To: …… Treating medical practitioner Fit for suitable duties (restricted return to work) .. From: …… To: …… Phone …… Job description: …… Task details Week Duties Restrictions Week 1 – commencing: …… …… …… Days: …… Hours: …… Week 2 – commencing: …… …… …… Days: …… Hours: …… Week 3 – commencing: …… …… …… Days: …… Hours: …… Week 4 – commencing: …… …… …… Days: …… Hours: …… Treatment occurring during this plan (e.g. physiotherapy): Training required: Yes No …… If ‘Yes’, given by: …… Plan to be reviewed on: …… Training given on: …… Signatures Treating medical practitioner Worker