PARTS A AND E OF THIS MEDICAL CERTIFICATE COMPRISE AN APPROVED FORM UNDER THE WORKERS’ COMPENSATION AND REHABILITATION ACT 2003
Tick  if applicable, and fill in the information as requested. 
☐  New Claim
Claim Number <<Claim Number>>

PART A - Worker’s details
I certify that on <<Date of Visit>> I attended to (given names) <<Patient Demographics:First Name>> (surname) <<Patient Demographics:Surname>>  (DOB) <<Patient Demographics:DOB>>
Worker’s daytime contact phone number <<Patient Demographics:Phone (Mobile)>>
Worker’s employer name <<Worker's Employer Name>>
The worker is/was suffering from (list all medical/dental diagnoses relevant to the claim):
Diagnosis: <<Diagnosis Relevant to Claim>>
☐ This is a provisional diagnosis (if provisional complete Part B)
Worker was first seen at this practice/hospital for this injury/disease on <<First seen for Injury>>
Worker stated date of injury <<Worker stated dated of injury>>
Worker’s stated cause of injury (if not previously supplied): <<Stated cause of injury>>
Injury/disease is consistent with worker’s description of cause: ☐ Yes ☐  Uncertain 
Detail any pre-existing factors or condition aggravated by the event (if not previously supplied):    <<Relevant Pre-existing factors>> 
Worker’s capacity for work (not only pre-injury duties)
Please consider the “health benefits of work” when certifying the worker’s capacity 
☐ To return to normal duties from <<Fit to return to normal duties from>>
☐ For suitable duties from ...../...../.... to ...../...../.....  (complete Part D)
☐ No capability for any type of work ..../..../..... to ..../..../...... (complete Part C)
Estimated time to return to some form of work duties: .... ☐ Days ☐ Weeks ☐ Unsure
Medical management 
☐ Worker will require treatment from ..../..../....  To ..../..../...  (complete Part C)
☐ Worker will be reviewed again on .../..../....   ☐ No further review  required
PART B - Diagnostic plan 
I have ordered ☐ Diagnostic Imaging ☐ Pathology ☐ Other Investigations
Details:<<Details of ordered Investigations>>

This form was approved by the Chief Executive Officer of Q-COMP, the Workers’ Compensation Regulatory Authority, on 4  June  2012, pursuant to section 586 of the Workers’ Compensation and Rehabilitation Act 2003. PRIVACY STATEMENT – Under the Workers’ Compensation and Rehabilitation Act 2003 and earlier Queensland workers’ compensation legislation, the workers’ compensation insurer is authorised to collect the information on this form to process the claimant’s application for compensation. Some or all of the information contained in this form may be disclosed to the claimant’s employer, another insurer, medical or allied health providers or any other workers’ compensation authority in any jurisdiction.

PART C - Medical management plan 
Treatment: <<Medical Treatment Plan>>
Medication prescribed: <<Medication prescribed>>
Referred to specialist (specialty/name): 
Referred to allied health professional (discipline/name): 
Detail (specify): <<Management Plan Detail>>
I would like the insurer to arrange a case conference with (tick more than one if appropriate)
☐  Treating practitioner  ☐ Treating Specialist  ☐ Treating Allied Health  ☐ Employer
☐  Employer has been contacted
☐  I would like the insurer to contact me 
Further information: 

PART D - Rehabilitation and return to work plan
 ☐ Approval is given for a suitable duties program with the following guidelines
				No     Occasional   Frequent	 	Comments
Lifting: weight limit ..... Kg 		☐	☐  	☐	  .......................................
Bending/twisting/squatting 		☐	☐      	☐	  .......................................
Standing/sitting		          	☐	☐	☐	  .......................................
Use of injured hand/arm		☐	☐	☐               .......................................
Pushing/pulling			☐	☐	☐	  ......................................
Operating machinery	/heavy vehicle	☐	☐	☐	  ......................................
Driving a car			☐	☐	☐	  .......................................
☐ Keep wound clean and dry
Other considerations (specify): 
Restricted hours/days (specify): 
☐ I require a suitable duties program to be provided to me for approval 
PART E - Medical/Dental practitioner details (please print clearly or use practice or hospital stamp)
Doctor’s name:<<Doctor:Fistname>> <<Doctor:Lastname>>  Practice/hospital name: <<Practice:Name>>
Postal address: 
Preferred method of contact:  ☐ Ph:<<Doctor:Phone>>    day(s)/time(s) 
☐ Fax: <<Doctor:Fax>>  ☐ Email: <<Doctor:E-Mail>>	

Signature: 		 		  Date: <<Miscellaneous:Date>>

Original signed copy – Insurer | Second copy – Employer | Third copy – Worker | Fourth copy – Medical/Dental Practitioner