Return to Work
Coordinator Toolkit
Contents
This is a toolkit for Return to Work Coordinators (coordinators). It contains:
First contact checklist – a step by step guide to what a coordinator needs to do when a worker is injured
Letters to treating doctor – templates a coordinator can use to introduce themselves to the treating doctor
Authority to release and obtain information
Recovery and return to work procedures to be modified to suit the workplace
Work capacity form – used to request more detailed information about capacity from the treating doctor
Information for a worker with a work injury
Further templates are available from your agent’s website (e.g. Travel reimbursement forms) and from the
ReturnToWorkSA website (e.g. Recovery/return to work plans). Coordinators are encouraged to arrange a suite of
tools and forms to use when needed.
ReturnToWorkSA has partnered with Return to Work
Matters to provide access to online injury management
information to support coordinators.
Return to Work Matters website access is available for
South Australian certified coordinators.
Registration is free and includes access to:
Handbooks, tools, resources, articles, online training and
webinars developed by leaders in Occupational Medicine,
return to work facilitation, policy development and
professional network support.
RTW Matters website link
First contact checklist (type)
1.
Name of worker:
Click here to enter text.
2.
Worker’s contact details:
Click here to enter text.
3.
Nature of injury:
Click here to enter text.
4.
Cause of injury:
Click here to enter text.
5.
Date of injury:
Click here to enter text.
6.
Department/location:
Click here to enter text.
7.
Current position:
Click here to enter text.
8.
Days/hours worked:
Click here to enter text.
9.
Supervisor’s name:
Click here to enter text.
10. Supervisor’s contact details:
Click here to enter text.
11. Principal/ manager advised that the worker has
sustained an injury:
Yes
No
12. Accident/incident investigated; corrective
actions taken; outcome discussed with worker:
Yes
No
13. Initial interview conducted with worker:
Yes
No
14. Work Capacity Certificate provided:
Yes
No
15. Name of treating doctor:
Click here to enter text.
16. Treating doctor’s contact details:
Click here to enter text.
17. Worker understands the nature of their injury,
treatment needs, expected outcome and is
comfortable with their treating doctor:
Yes
18. Specialist/other treatment providers involved:
Click here to enter text.
19. Worker provided with injury pack:
Yes
No
20. Confidentiality discussed and worker asked to
sign Authority to Exchange Information:
Yes
No
21. Letter given/sent to doctor with signed Authority
to Exchange Information:
Yes
No
No
22. Claim Form completed:
Yes
No
23. Claim Form and Work Capacity Certificate sent
to claims agent with 12 months of pay history:
Yes
No
24. Travel and Chemist Reimbursement Forms:
Yes
No
25. Special needs identified (e.g. capacity to drive a
motor vehicle, interpreter required):
Click here to enter text.
26. Concerns and/or potential barriers to return to
work explored and addressed:
Click here to enter text.
27. Record capacity for work from Work Capacity
Certificate:
Click here to enter text.
28. Capacity for work discussed with worker and
supervisor; suitable duties identified:
Yes
No
29. Prepare recovery/return to work plan (with
worker/supervisor) and forward to claims agent
for approval:
Yes
No
30. Contact claims agent and advise of actions taken
to date:
Click here to enter text.
31. Establish a confidential file; keep case notes and
detail all communication, actions and decisions.
Yes
No
32. Diarise for follow up (date, milestone):
Yes
No
Notes:
Letter to treating doctor
Dr
Address
Fax/email
Dear
I understand that you are the treating doctor for ……………………….…………..(name), who works for
……………………….…………..(company name) as a ……………………….…………..(position).
I am the return to work coordinator for ……………………….…………..(company name).
Wherever possible, ……………………….…………..(company name) will provide suitable duties for
……………………….…………..(name) during their recovery, including being flexible about hours of attendance and
accommodating medical restrictions.
To assist you to determine ……………………….…………..(name) work capacity I have enclosed a copy of their job
description and a list of alternative duties that may be suitable. If you require more information or would like to
arrange a visit to the workplace to determine the suitability of duties available, please do not hesitate to
telephone me on (phone number).
We look forward to working with you to assist ……………………….…………..(name) in their recovery and return to
work.
A copy of ……………………….…………..(worker’s name) signed authority to exchange information is attached for
your records.
Yours sincerely
(Name)
Return to work coordinator
(Date)
Letter to treating doctor
Dear Doctor
I am the return to work coordinator for (company name).
(Company name) is committed to the safe and early return to work of any employee who is injured at work.
Wherever possible we will provide suitable duties during their recovery, including being flexible about hours of
attendance and accommodation of medical restrictions.
To assist us provide suitable duties for your patient we would be grateful if you would complete the enclosed work
capacity form. This will enable us to ensure that your patient returns quickly and safely to suitable work.
If you require more information or would like to arrange a visit to the workplace to determine the suitability of the
duties available, please do not hesitate to telephone on (RTWC phone number).
We look forward to working with you to assist our employee in their recovery and return to work.
Yours sincerely
(Name)
Return to work coordinator
(Date)
Medical authority
I, Click here to enter worker’s full name, give permission for my treating doctor and/or medical experts, Click here
to enter name(s), to provide my employer’s appointed return to work coordinator, Click here to enter name, with
information relating, and/or relevant, to my work injury or illness, Click here to enter injury or illness details
Worker’s full name: Click here to enter full name
Worker’s signature:
Date: Click here to enter a date.
Recovery and return to work procedure
1. Purpose or Remain at work/return to work policy statement
Our company is committed to helping workers with a work injury to remain at or return to work. We support our
workers by having a system for recovery and return to work and providing suitable duties whilst recovering.
This procedure describes the processes for the management of recovery and return to work.
2. Scope
This procedure applies to here to enter details
3. Supporting documents
Recovery and return to work policy
4. Related documents
4.1 Return to Work Act 2014
4.2 Return to Work Regulations 2015
4.3 Grievance and Dispute Resolution Procedure, Equal Opportunity Policy etc.
5. Recovery and return to work
5.1 Reporting of injury
• A worker who is injured at work should report the incident to their supervisor/team leader as soon as
practicable or within 24 hours.
• Insert details of employer’s reporting procedure.
• The supervisor/team leader will immediately advise the return to work coordinator (coordinator) that the
worker has been injured.
• A coordinator is appointed by the employer and has the following functions:
a) Help workers remain at or return to work
b) Prepare or contribute to the preparation of a recovery/return to work plan
c) Liaise with medical and other service providers
d) Monitor the progress of a worker’s capacity for work
e) Take steps to prevent re-injury when a worker returns to work
5.2 Injury pack is given to the worker with a work injury
The coordinator (supervisor/team leader) will give the person with a work injury the injury pack and explain
the contents, as appropriate:
•
•
•
•
•
•
Claim form
Authority to release information
Letter to the doctor
Worker’s rights and responsibilities under the Act
Travel Reimbursement Form
Pharmacy Reimbursement Form
5.3 Medical treatment
If the worker requires immediate treatment they will be accompanied to the medical clinic or hospital if
appropriate, so return to work strategies and suitable duties can be discussed with the treating doctor.
Insert details about how the injured worker will be transported and who will accompany them
5.4 Lodge the claim
The coordinator (supervisor/team leader) will assist the worker to lodge the claim.
Insert details about how this will be done
5.5 Identify suitable duties
If the worker’s capacity for work is unclear, the coordinator will contact the treating doctor to clarify
The coordinator will meet with the worker and the supervisor/team leader to identify and agree upon suitable
duties for the worker
Insert details about how this will be done
The coordinator will document the suitable duties and may prepare a recovery/return to work plan.
5.6 Recovery and return to work needs determined
If specialist expertise is not available in the workplace is required, the coordinator will communicate with the
claims agent regarding a referral for return to work services.
The claims agent will make any referrals for return to work services.
5.7 Implementation of return to work
The coordinator will ensure that the information given to the worker about their return to work arrangements
is clear, accurate and current.
The coordinator will ensure that the worker receives any necessary training (including work health and safety)
before the worker with a work injury undertakes any modified or alternate duties.
5.8 Monitor progress
The coordinator will review progress:
-
when a new WMC is received
at significant milestones
when the worker provides new information
by visiting the worker and supervisor/team leader
by convening or attending case conferences
staying in touch with the treating doctor
The worker’s duties and/or hours of work will be adjusted in response to changes in the extent of their
capacity for work and any new information available.
5.9 Return to pre-injury duties
When the worker returns to their pre-injury duties, the coordinator will notify the claims agent and close the
return to work file.
5.10 Worker is unable to return to pre-injury duties
If the worker is unable to return to his pre-injury duties, (employer name) will make every effort to identify
and offer other suitable employment
(employer name) may require additional information in order to be able to identify suitable employment for
the worker. A functional capacity evaluation, worksite assessment and/or vocational assessment may be
required in order to determine the suitability of employment
The coordinator will discuss the need for any such return to work assessment services with claims agent
The coordinator will ensure the worker receives any necessary training (including work health and safety)
before commencing any new employment.
5.11 Unable to identify suitable employment
If (employer name) is unable to identify suitable employment for the worker the claims agent must be
promptly notified.
The claims agent will determine whether or not it is reasonably practicable for (employer name) to provide
suitable employment.
6. Other matters
6.1 Grievances in relation to recovery and return to work
Insert details of your grievance/dispute resolution procedure
6.2 Confidentiality
Information obtained during recovery and return to work will be treated with sensitivity and confidentiality.
Information about medical authority, to whom and under what circumstances information will be released
6.3 Case notes and records
The coordinator will keep accurate and objective case notes in a secure location for each worker with a work
injury undergoing return to work.
Insert details of what case notes must contain, storage and archiving of case notes
6.4 Information and training
Information and training regarding recovery and return to work procedures will be available for managers,
supervisors/team leaders and workers
Recovery and return to work information will be included in induction programs for new employees.
7. Responsibilities
7.1 Employer
Insert responsibilities
7.2 Coordinator
Assist a worker with a work injury to remain at work, or return to work as soon as possible, after they have
sustained an injury
Assist in the preparation and implementation of a recovery/return to work plan
Liaise with any persons involved in the return to work, or the provision, of medical services to the worker with
a work injury
Monitor the progress of the worker’s capacity to return to work
Take steps to prevent the occurrence of secondary disabilities when the worker returns to work.
7.3 Managers and supervisors
Insert responsibilities
7.4 Worker
Insert responsibilities
7.5 Worker with a work injury
Insert responsibilities
7.6 Coordinator
8. Review of this procedure
Click here to insert details of when and how this procedure will be reviewed
Approved by: Click here to enter name
Signature:
Position: Click here to enter position details
Date: Click here to enter a date.
Work capacity form
Patient and employer details
Family name ___________________________________- Given names ___________________________________________
Claim number (if known) _______________ ___ _____ Employer name ___________________________________________
D.O.B. Click here to enter a date.
☐Your ability to work is affected by _Injury______ (injury) ______ as follows:
Physical function
Sitting
Standing/walking
Kneeling/squatting
Carrying/holding lifting
Reaching above shoulder
Bending
Use of affected body part
Neck movement
Climbing steps, stairs, ladders
Driving
Can
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
With
modifications
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
Cannot
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
Comments
(eg details of capacity or limitations that will assist in
identification of suitable duties)
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
Mental health function
Attention/concentration
Memory
(short and/or long term)
Judgement
(ability to make decisions)
Not
affected
☐
Partially
affected
_____________________________________________
Affected
_____________________________________________
☐
☐
☐
☐
☐
_____________________________________________
☐
☐
☐
_____________________________________________
☐Other functional considerations – not listed above
_____________________________________________
_____________________________________________
______________________________
(please provide details in the comments section)
☐I have prescribed medication that could impact on your ability to undertake some activities
Details: ______________________________________________________________________________________________
I recommend:
☐A graduated increase in working hours over___ weeks from ___hours a day to your normal hours/___hours a day.
☐Non-consecutive working days for a period of ___days or ___weeks
☐I would like more information about the options available for your return to work
Doctor’s details
Doctor’s name ______________________________ Provider number ___________________________________
Address _____________________________________ Email address ____________________________________
____________________________________________ Fax ______________________________________________
____________________________________________ Signed __________________________________________
Completion date Click here to enter a date.
Information for a worker
Injured at work?
Following your injury, it is very important that the following things occur:
1. Immediately notify your employer (supervisor or manager) and seek necessary first aid treatment
Your employer can assist you to access the appropriate treatment for your injury and will also assist you to
complete a claim form with them to notify ReturnToWorkSA and its claims agents of your injury.
2. If you require further medical assessment your employer will help you arrange to see a doctor
The doctor will assess you to decide what injury you have suffered and what kind of treatment you require. They
will also issue a Work Capacity Certificate, which you will need to provide to your employer.
3. Lodging a claim
The claim form you complete with your employer will be sent to a claims agent acting on behalf of
ReturnToWorkSA. Lodging the form will ensure that you may be eligible to income support if you can’t work and
also cover medical or other expenses incurred. The claims agent will assign a case manager who will contact you
to obtain further information about your injury and claim and ensure that you receive the right treatment, care
and support to help you recover and return to work as soon as possible.
How ReturnToWorkSA and your employer will support you
If your injury arises from your employment, you may receive:
• income support to cover your wages for up to two years
• reasonable and necessary medical treatment and care for up to three years
If you are not likely to fully return to work in two weeks, your claims agent will likely send a case manager to visit
your worksite to meet both you and your employer. They can then assist you to continue to see the correct
treatment providers and to receive the care and support services to help you to recover and get back to work as
soon as possible.
These face-to-face worksite visits will occur as soon as possible after your injury has been notified to the claims
agent and will continue until you recover and return to work.
Your case manager will also assist you and your employer to develop a recovery and return to work plan if you are
not able to return to the hours that you were working before your injury after 4 weeks.
Your case manager may also arrange to meet with you and your treating medical team to discuss your recovery
and return to work plan.
Your rights
If you have suffered a work injury you can expect:


early intervention and appropriate support services
income support if you are unable to return to work or to your normal working hours


the support of your employer whilst you recover and return to work
open and transparent communication from all people involved in your claim
Your responsibilities
If you have suffered a work injury you will be expected to:
• participate in activities that will assist you to recover and return to work
• assist in the development of your recovery and return to work plan (if required)
• complying with any obligations set out in your recovery and return to work plan
• provide current work capacity certificates and recommendations from your doctor
• meet with your employer and your case manager to discuss your recovery and return to work plan
• return to work as soon as your doctor says that you can
Your employer's obligations
We expect your employer to support your recovery and return to work by:
• notifying their claims agent of your work injury within 5 days of receiving notice of your injury
• participating in the development of your recovery and return to work plan
• complying with any obligations set out in your recovery and return to work plan
• providing suitable duties that you can perform safely as you recover from your injury
• providing suitable employment when you are fit to return to work, if you cannot return to pre-injury work.
Some recovery and return to work tips:
Talk to your employer and ask about suitable duties and suitable employment – keep the lines of communication
open with your return to work coordinator and supervisor. You could also ask your doctor to call your return to
work coordinator to discuss your return to work.
Stay active – continue with your usual activities as much as you can. Seek advice from your doctor and other
activities about activity and exercise.
Stay in touch with your workmates and friends. Job satisfaction and social contact are some of the things you are
likely to miss while you’re away from work. It can be lonely staying at home all day. Continuing with your regular
social activities as much as possible helps your recovery.
Accept help from your friends and family – talking about your needs and accepting help from family and friends is
a positive step towards your recovery.
Stay positive and focus on what you can do – rather than dwelling too much on what you can’t.
If you require more information please talk to your coordinator or your case manager