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 1 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 2 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: 3 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) 4 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 7 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 8 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. 9 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