Community Integration Program Claim Review
Summary Form: Spinal
Please complete this form for injured workers with an eligible spinal cord injury for
transfer into the Community Integration Program.
Date sent to WorkSafe:
Agent: _____________________________
Contact Name: ______________________
Date received by WorkSafe:
Agent: _____________________________
Contact Name: ______________________
Return all completed forms and supporting documentation to:
Health Operations (Community Integration Program)
WorkSafe Victoria
Level 21
222 Exhibition Street
Melbourne VIC 3000
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This information is to be considered indicative only – eligibility for transfer to the TAC for the WorkSafe Victoria /TAC Community
Integration Program is subject to WorkSafe Victoria confirmation and endorsement
Community Integration Program Claim Review Summary
Form: Spinal
Note:

Information for this summary is to be retrieved from the file or ACCtion only. No
additional contact is to be made with THP or worker at this stage. If information
cannot be located, please indicate on form.

Please photocopy supporting material as you go. This will form the basis of the TAC
file, together with ensuring the accuracy of all collected information.
WorkSafe Victoria Agent:
Claims Manager Name:
Direct Contact Number:
Claim Status: (select one)
Worker’s Details
WorkSafe Victoria Claim No:
Worker name:
Date of Birth:
Current Age:
Worker Address:
Worker Phone number:
Key emergency contact/s: (if relevant)
Administrator/Guardian details (if relevant):
Name
Phone
Relationship
Domestic status:
Name
Age (if relevant)
Living with worker
No
Partner:
Yes
Child :
Yes
No
Parent (s):
Yes
No
Siblings:
Yes
No
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This information is to be considered indicative only – eligibility for transfer to the TAC for the WorkSafe Victoria /TAC Community
Integration Program is subject to WorkSafe Victoria confirmation and endorsement
Injury Details
Date of Injury:
Summary of accident:
Generic Injury description: (e.g. C6 incomplete quad)
Detailed injury description:
Acute Hospital details:
Consultant’s name:
Rehabilitation Hospital details:
Consultant’s name
Post injury surgery
Date
Surgery type /
detail
Outcome
Name of
Surgeon /
Hospital
Current issues
Summary of pre-injury details

Pre-injury medical status/conditions:

Pre-injury medications/rationale:

Pre-injury physical status:

Pre-injury psych status:

Pre-injury cognitive status:

Pre-injury ADL independence:

Pre injury domestic status:

Pre-injury residential status:
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This information is to be considered indicative only – eligibility for transfer to the TAC for the WorkSafe Victoria /TAC Community
Integration Program is subject to WorkSafe Victoria confirmation and endorsement
Current Status

Residential status:

Medical status:

Conscious state / cognition:

Communication:


Physical/mobility:
Psych / behaviour:

Neuropsychology reports:

Social:

Education / Employment:

Recreational involvement:

Personal Activities of Daily Living (PADL)/Domestic Activities of Daily Living (DADL)/
Communication Activities of Daily Living (CADL):
Current Medications
(Please copy and attach last 2 pharmacy invoices)
Medication Name
Prescribed Reason
by (if
known)
Injury related or preexisting
Dosage (If
available)
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This information is to be considered indicative only – eligibility for transfer to the TAC for the WorkSafe Victoria /TAC Community
Integration Program is subject to WorkSafe Victoria confirmation and endorsement
Current Service Provider Summary
Name /
Company
Service Current
approved hours
/ frequency
Contact
details
Comment Commencement of
date of service
Current Medical / Paramedical / Rehabilitation Provider Summary
(Please attach a copy of the current treatment notification form.)
Name /
Company
Discipline
Current
approved
hours/
frequency
Treatment/
Intervention
goals
Contact
details
Comment
Commen
cement
date of
service
Current Vocational Status

Pre injury / current occupation:

Pre injury employer:

Existing relationship with pre-injury employer:

Existing RTW plan / suitable employment offer:

Return to work status (e.g. current hours / duties / previous attempts to RTW:

Level of education attained:

Any post injury training / retraining:
5
This information is to be considered indicative only – eligibility for transfer to the TAC for the WorkSafe Victoria /TAC Community
Integration Program is subject to WorkSafe Victoria confirmation and endorsement
Current Equipment Summary
Equipment Type /
Modification
Details
Date
Cost (if
relevant)
Date of next
review /
Comment
Wheelchair
Recreational
equipment
Vehicle
Home
modification
Other:
Worker Objectives

Home/Living:

Vocation/Education:

Recreation/Leisure:

Community Independence:
Common Law / Dispute resolution / Impairment / Income

Common Law:

Dispute resolution:

Impairment:

Income:
6
This information is to be considered indicative only – eligibility for transfer to the TAC for the WorkSafe Victoria /TAC Community
Integration Program is subject to WorkSafe Victoria confirmation and endorsement
Termination/ Reduction in services:
Service type
Date of
Reasons for
Disputation
termination/reduction termination/reduction details
(if applicable)

Please attach payment sheet summary (from ACCtion) detailing all Medical and
Like costs to date.
Eligibility Assessment
Agent
Select option
Case Manager
CM Review date
MDT Case Conference
date
IMA review date
IMA endorsement
(Specify IMA)
Injured worker
Claim No:
Date of injury
Date of claim:
Type of injury (please
specify with  )
Quadriplegia
Paraplegia
Agent review outcome:
The injured worker outlined above has been identified as meeting the definition of a catastrophic
injury for the purposes of the Community Integration Program and may be eligible for transfer to the
TAC.
Claim status (specify):
New claim (< 6 months from date of injury)
Existing claim (> 6 months from date of injury):

Attach completed claim summary tool

Attach completed Community Integration Program Spinal Functional & Mobility Outcome
Coding
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This information is to be considered indicative only – eligibility for transfer to the TAC for the WorkSafe Victoria /TAC Community
Integration Program is subject to WorkSafe Victoria confirmation and endorsement
Specify information source (provide all relevant attachments i.e. Certificate of Capacity, TP
reports).
WorkSafe Victoria/TAC Community Integration Initiative Spinal Functional Coding
Please enter one tick per section (ASIA Code, Mobility Code and Quadriplegics only- Ventilated) to
indicate the injured worker’s current status.
ASIA Code – Spinal
Complete
A
Complete disruption of function and sensation
B
Complete disruption of motor function, some sensation
Incomplete
C
Some weak motor function, and some sensation
Incomplete
D
Some strong motor function and sensation
Incomplete
E
Near normal motor function and sensation
Incomplete
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This information is to be considered indicative only – eligibility for transfer to the TAC for the WorkSafe Victoria /TAC Community
Integration Program is subject to WorkSafe Victoria confirmation and endorsement
Mobility Code - Spinal
A
Limited head and neck movement (C1-C3)
Quads
B
Head and neck control may shrug shoulders (C4)
Quads
C
Has shoulder control and can bend elbows with palms up (C5)
Quads
D
As above (C) plus can extend wrists and turn palms up & down (C6)
Quads
E
As above (C & D) plus limited to natural hand function (C7-C8)
Quads
F
Full UL control, limited upper trunk stability (T1-T4)
Para
G
As above (F) plus fair to good upper trunk stability (T5-T9)
Para
H
As above (G) plus good trunk control T10-L1)
Para
I
As above (H) plus partial or full control of lower extremities (L2-S5)
Para
Quadriplegics Only - Ventilated
Yes
No
-------------------------------End of form-------------------------------Please turn over for the CIP Supporting Documentation
checklist.
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This information is to be considered indicative only – eligibility for transfer to the TAC for the WorkSafe Victoria /TAC Community
Integration Program is subject to WorkSafe Victoria confirmation and endorsement
Community Integration Program Supporting
Documentation Checklist: Spinal
Please tick each box once the relevant documentation has been attached. All boxes
must be ticked before submitting your forms to WorkSafe Victoria.
SPINAL CLAIM
 Community Integration Program Claim Review Summary Form (Spinal)
 Last two pharmacy invoices attached (copies only)
 Current treatment notification form attached (copies only)
 Payment sheet summary from ACCtion printed and attached, detailing medical
and like costs to date
 Claim summary tool attached
 Community Integration Program Spinal Functional & Mobility Outcome
Coding attached
 Information source attached (i.e. Certificate of Capacity, TP reports)
PLEASE NOTE: All sections of each form must be filled out in full. Blank
sections or missing documents may result in your form being returned to you for
clarification. This will cause delays in processing your claim review.
10
This information is to be considered indicative only – eligibility for transfer to the TAC for the WorkSafe Victoria /TAC Community
Integration Program is subject to WorkSafe Victoria confirmation and endorsement
Further Information
If you need advice or further information about the Community Integration Program or eligibility criteria,
please contact the following representatives:
Community Integration Program Manager
WorkSafe Victoria
222 Exhibition Street
Melbourne Vic 3000
Phone: 03 9940 4073
Team Manager
Community Integration Program
Transport Accident Commission (TAC)
PO Box 2401
Geelong Vic 3220
DX 216063
Phone: 03 5225 6497
Toll free: 1800 651 953
11
This information is to be considered indicative only – eligibility for transfer to the TAC for the WorkSafe Victoria /TAC
Community Integration Program is subject to WorkSafe Victoria confirmation and endorsement