Community Integration Program Claim Review
Summary Form: Acquired Brain Injury (ABI)
Please complete this form for injured workers with an eligible acquired brain 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:
ABI
Note:
1. 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.
2. 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
Partner:
Yes
No
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. moderate severe ABI)
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
Commencement
of 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
termination
/reduction
Reasons for
termination/reduction
Disputation
details
(if applicable)
Please attach payment sheet summary (from ACCtion) detailing all Medical and Like
costs to date.
Eligibility Assessment
Agent
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:
Agent review outcome:
The injured worker outlined above has been identified as meeting the WorkSafe Victoria/TAC definition of a
catastrophic injury for the purposes of the Community Integration Program and may be eligible for transfer.
Claim status:
New claim (< 6 months from date of injury)

Provide the following information:
Severe ABI
Indicator
Actual Score
Moderate ABI
Indicator
GCS
GCS
PTA
PTA
Actual Score
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
Existing claim (> 6 months from date of injury):
 Attach completed claim summary tool
 Attach completed ABI Functional & Mobility Outcome Coding
Specify information source (provide all relevant attachments i.e. Certificate of Capacity, TP reports).
ABI Functional & Mobility Outcome Coding
Please refer to the Functional Outcome Scale on Pages 10-13 before completing the table below. For
further information, refer to the full ABI Functional Outcome Scale at the end of this form.
Functional outcome scale
1.
2.
3.
4.
5.
Minimal function
Conscious but dependent
Dependent in most tasks
Independent but disabled
Independent mild residual deficits
Severity / skill
Functional
Description of function (brief)
Outcome
rating 1-5 (see
above)
1. Conscious state
2. Cognition
3. Communication
4. Level of supervision
5. Personal care
6. Other Activities of
Daily Living (ADL’s)
7. Mobility
8. Accommodation
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
9. Access /
social/recreational
10. Vocational options
11. Concurrent issues
12. Psychological
status / behaviour
Total score
The total score is derived by calculating the sum of each of the
above functional outcome ratings
Average
The average functional outcome score is derived from dividing
the sum of the total score by 12.
Functional Outcome
ABI Mobility code
Please indicate client’s current level of mobility for each limb.
Left LEG
Right LEG
Left ARM
Right ARM
No use
Some use
Full use
-------------------------------End of form-----------------------------Please turn over for the CIP Supporting Documentation checklist and ABI
Functional Outcome Scale reference.
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: Acquired Brain Injury (ABI)
Please tick each box once the relevant documentation has been attached. All boxes must
be ticked before submitting your forms to WorkSafe Victoria.
ABI CLAIM
 Community Integration Program Claim Review Summary Form (ABI)
 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
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
ABI Functional Outcome Scale
Severity
1
Skill
Most severe
General
Functional level
Minimal
Function
Conscious but
dependent
Dependent in
most tasks
Independent
but disabled
Independent
with mild
residual
deficits
1.
Vegetative
state
Generally alert
– may be
disorientated
Alert and
generally
orientated
Alert and
orientated
Alert and
orientated
Non responsive
Severe
cognitive
deficits
Follows
commands,
reduced capacity
for decision
making, problems
with memory,
new learning
Assistance
needed with
planning,
organisation,
decision
making –
insight may be
a problem
Higher
level/mild
cognitive
deficits in
organisation,
planning:
fatigue can be
a problem;
generally
insightful
No
discernible
skill
Some
moderate
prompting
Problems with
increased length
or complexity of
spoken or written
language;
frequently
inappropriate in
social context
Problems with
retention; may
be verbose,
tangential or
disinhibited
Mild, high level
abstract
language
problems; may
be
inappropriate or
face difficulty
under pressure
Total assist –
24 hour
hands-on
care
Close
supervision,
cannot be left
alone at night;
significant
attendant care
Supervision,
including care, in
unstructured
settings
Some
supervision
with new,
complex
activities; may
have low level
care program
Independent
Fully
dependent
Dependent with
personal care;
always needs
assistance/sup
ervision/set up/
contact/mod
assist
Able to care for
self partially,
sometimes needs
supervision/min
assist with ADL
Independent
Independent
Conscious
State
2.
Cognition
2
Communication
4.
Level of
supervision
(safety),
including care
(funded or
other)
5.
Personal Care
4
Moderate
(Includes memory,
concentration,
attention,
orientation, problem
solving, safety
judgment, learning,
organisation,
insight…)
3.
3
5
Most mild
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
Severity
1
Skill
Most severe
General
Functional level
Minimal
Function
Conscious but
dependent
Dependent in
most tasks
Independent
but disabled
Independent
with mild
residual
deficits
6.
Fully
dependent
Dependent,
mod assist with
DADL & CADL;
cueing/assist
with public
transport
Assistance of
some level (either
personal,
domestic,
community)
assistance to
access
community –
public transport,
social pursuits
due to safety
issues
Gets out and
about to shops,
uses public
transport or
drives,
sometimes
needs
assistance with
ADL’s (may be
linked to ortho
injuries)
Generally
independent
including public
transport or
driving; minimal
physical deficits
Fully
dependent
Accompanying
physical
disability/
mobility,
reduced
coordination,
may be
wheelchair
dependent;
assist with
transfers
Walking or
wheelchair
independent;
more physically
able
Independent
may have
ongoing
physical
complications
from coexisting ortho.
Injuries
Independent
Nursing
home or
equivalent
level of
accommodati
on
Supported
residence
(institution or
home with
family/carers)
Either in
community with
support or
supported
residence
Able to live
independently
with regular
non-residential
support
Independent
N/A
Discontinued
relationships,
unable to return
to previous
social,
recreational,
vocational
activities
Suitable for
supported
recreational
services, may
need carer to
accompany,
difficulty
sustaining
independent
relationships/net
works
Not possible to
return to some
previous
activity (work,
school, social)
because of
cognitive/
physical deficits
Independent
Other ADLs
7.
Mobility
8.
Accommodation
9.
Access / social /
recreation
2
3
4
Moderate
5
Most mild
12
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
Severity
Skill
1
Most severe
2
3
Moderate
4
5
Most mild
General
Functional level
Minimal
Function
Conscious but
dependent
Dependent in
most tasks
Independent
but disabled
Independent
with mild
residual
deficits
10.
N/A
Unlikely to
return to work
or any
avocational
activity
Some possibility
of RTW with
extensive
support; unlikely
to compete in
open job market;
volunteer work a
possibility
Higher RTW
potential –may
be to different
role or adjusted
workload
RTW or school
potential with
average
performance;
high proportion
to pre-accident
role, compete
in open job
market
Medical
issues i.e.
high risk of
pneumonia,
epilepsy,
contractures
Medical issues
i.e. epilepsy
Medical issues
i.e. epilepsy. Preexisting problems
(drug & alcohol,
social
personality) may
impact on
outcome
Pre-existing
problems (drug
& alcohol,
social
personality)
may impact on
outcome
Pre-existing
problems (drug
& alcohol,
social
personality)
may impact on
outcome
N/A
Depression.
Psych status
may effect
management;
less ability to
‘act out’ but
behaviour may
be an issue.
Moderate risk of
demonstrating
behavioural
problems,
agitation,
aggression,
impulsivity,
withdrawn,
adynamic; risk of
self harm or harm
to others;
isolated.
Depression
High risk of
demonstrating
behavioural
problems,
agitation,
aggression,
impulsivity,
withdrawn,
adynamic; risk
of self harm or
harm to others;
isolated.
Depression
Low risk of
demonstrating
behavioural
problems,
agitation,
aggression,
impulsivity,
withdrawn,
adynamic; risk
of self harm or
harm to others;
isolated.
Depression or
Post Traumatic
Stress disorder
possible.
Vocational
options
11.
Concurrent
issues
12.
Psychological
status/
behaviour
13
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
14
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