Certificate of capacity/ certificate of fitness

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Certificate of capacity/

certificate of fitness

For use with workers compensation and Compulsory Third Party (CTP) motor

accident injury claims.

CTP Workers compensation

For CTP claims: ‘Certiﬁcate of ﬁtness’ means ‘certiﬁcate of ﬁtness for work’. This certiﬁcate should be completed whether the person

was employed at the time of the accident or not.

Tick if this is the initial certiﬁcate for this claim.

Section 1: To be completed by the injured person or treating medical practitioner

First name Last name

Date of birth (DD/MM/YYYY) Telephone number

Address (must be residential address – not PO Box) Suburb

State Postcode Claim number Medicare number

Occupation/job title Employer’s name and contact details (if applicable)

Injured person’s consent

I consent to my treating medical practitioner, my employer (optional for CTP claims), the insurer, other

medical practitioners or health related practitioners (whether consulting, treating or examining), workplace

rehabilitation providers and SIRA exchanging information for the purpose of managing my injury and

workers compensation/motor accident injury claim.

I understand this information will be used by SIRA and insurers to fulﬁll their functions under the motor

accident insurance and workers compensation legislation.

Signature Date (DD/MM/YYYY)

Section 2: To be completed by treating medical practitioner

Medical certification

Diagnosis of work related injury/disease or motor accident related injury(ies)

Person’s stated date of injury/accident

(DD/MM/YYYY)

Shaded areas to be completed for initial certificate only

Person was ﬁrst seen at this practice/hospital

forthis injury on (DD/MM/YYYY)

Injury is consistent with person’s description

of cause

Yes No Uncertain

How is the injury related to work or the motor vehicle accident?

Detail any pre-existing factors which may be relevant to this condition or injury(ies)

SAVE AS

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First name Last name Claim number

Management plan for this period

Treatment/medication type and duration

Referral to another health service or rehabilitation provider (include details of provider type and service

requested, duration and frequency when relevant)

Capacity for activities – If the person has capacity for pre-injury work this section does not need to be

completed. For all others please consider activities of daily living currently being performed.

Lifting/carrying capacity Sitting tolerance

Standing tolerance Pushing/pulling ability

Bending/twisting/squatting ability Driving ability

Other (please specify) eg psychological considerations, keep wound clean and dry

Next review date

(DD/MM/YYYY)

(if greater than 28 days,

please provide clinical reasoning)

Comments

Capacity for work (please consider the health benefits of good work when completing this section).

Where the word ‘capacity’ appears below it should be read as ‘ﬁtness for work’ when the certiﬁcate is

completed in a motor accident injury claim.

Do you require a copy of the position description/work duties?

s No

Date

(DD/MM/YYYY)

is ﬁt for pre-injury work

from

has capacity for some

type of work from

to for hours/day days/week

has no current capacity

for any work from

If no current capacity for work, estimated time to return to any type of employment

Factors aecting recovery

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First name Last name Claim number

Treating medical practitioner details

I certify that I am the treating medical practitioner and I have examined this person. The information and

medical opinions contained in this certiﬁcate are, to the best of my knowledge, true and correct.

Signature Date (DD/MM/YYYY)

Name

Address

Suburb State Postcode

Telephone number Provider number

I agree to be the nominated treating doctor for the ongoing management of this person’s injury,

treatment and recovery at/return to work (tick if you consent).

Section 3: Employment declaration (not to be completed by the treating medical practitioner)

This section is to be completed by the person prior to sending to the insurer (or employer).

First name Last name

I have I have not (tick appropriate box)

engaged in any form of paid employment, self employment or voluntary work for which I have received or

am entitled to receive payment in money or otherwise since the last certiﬁcate was provided, that I have

not yet declared to the insurer.

If so, please provide details below.

I declare that the details I have given on this declaration are true and correct, knowing that false declarations

are punishable by law.

Signature Date (DD/MM/YYYY)

Catalogue No. SIRA08719

State Insurance Regulatory Authority, 92–100 Donnison Street, Gosford, NSW 2250

Locked Bag 2906, Lisarow, NSW 2252 | Customer Experience 13 10 50

Website www.sira.nsw.gov.au