Forms

Here is a list of ReturnToWorkSA forms, sorted in alphabetical order.

For further information or advice, please contact us on 13 18 55 or email info@rtwsa.com.

If you experience any issues downloading forms, please contact us on 13 18 55.

Allied health mental functional capacity recommendation template
Mental health functional capacity recommendation template for Allied Health.

Application for review under Section 157 form
Registered employers should complete this form if they want a review of a decision about their insurance premium.

Authority to obtain information form (Amharic)
Authority to obtain information form translated to Amharic

Authority to obtain information form (Arabic)
Authority to obtain information form translated to Arabic

Authority to obtain information form (Chin Hakka)
Authority to obtain information form translated to Chin Hakka

Authority to obtain information form (Chinese)
Authority to obtain information form translated to Chinese.

Authority to obtain information form (Dari)
Authority to obtain information form translated in Dari

Authority to obtain information form (Dinka)
Authority to obtain information form translated in Dinka

Authority to obtain information form (English)
When completed, the authority to obtain information form gives the Return to work service provider permission to obtain information relevant to a workers return to work activity.

Authority to obtain information form (Hindi)
Authority to obtain information form translated to Hindi

Authority to obtain information form (Khmer)
Authority to obtain information form translated to Khmer.

Authority to obtain information form (Kurdish)
Authority to obtain information form translated to Kurdish.

Authority to obtain information form (Nepali)
Authority to obtain information form translated to Nepali

Authority to obtain information form (Persian)
Authority to obtain information form translated to Persian

Authority to obtain information form (Spanish)
Authority to obtain information form translated to Spanish.

Authority to obtain information form (Swahili)
Authority to obtain information form translated to Swahili.

Authority to obtain information form (Vietnamese)
Authority to obtain information form translated in Vietnamese.

Claim form
Call your claims agent EML 1800 688 825 or Gallagher Bassett 1800 774 177 to make a claim as this form may not be required.

Daily safety checklist for apprentices
Make safety part of every day with this safety checklist for apprentices.

Electronic funds transfer (EFT) form
Electronic funds transfer (EFT) form for medical, allied health and return to work service providers.

Employer request for claims information form
Employer request form for access to claims information

Exercise physiology management plan
Exercise Physiology Management Plan

Fit for work intervention outcome report template
Fit for work services intervention outcome report template.

Freedom of Information (FOI) application for access form
This form should be completed for Freedom of information requests.

Freedom of information (FOI) internal review application form
Please complete this form if you wish to request a review of a Freedom of information determination.

Graduated return to work schedule
If you are not able to return straight to your pre-injury duties following your workplace injury, you may need to return over a gradual period of time. This is when a graduated return to work schedule can be created.

Healthy Workplaces champion posters
Let your workers know who to contact to help your workplace thrive.

Impairment Assessment Guidelines GEPIC Worksheet
Impairment Assessment Guidelines Psychiatric Impairment Assessment GEPIC Worksheet

Insurance premium calculator
This premium calculator will provide you with an estimate for your ReturnToWorkSA insurance premium.

Interpreter declaration form
When an interpreter is used by ReturnToWorkSA or our providers, the interpreter should sign an interpreter declaration form.

Job placement services 13 week durability outcome report template
Job placement services 13 week durability fee outcome report.

Job placement services 26 week durability outcome report template
Job placement services 26 week durability outcome report template.

Medical expenses application for pre-approval form
Complete this form if you need to apply for pre-approval for medical expenses.

My treatment - what do I want to achieve form
This form is a valuable tool to help allied health practitioners treat patients' needs.

Noise induced hearing loss - additional information form
Form for additional information for noise induced hearing loss claims.

Nurse practitioner work capacity certificate
Nurse practitioners can use the Nurse Practitioner Work Capacity Certificate when a person with a new work injury presents to a hospital emergency department.

Occupational therapy management plan
Occupational Therapy Management Plan

Osteopathy management plan
Osteopathy Management Plan

Physiotherapy management plan
Physiotherapy Management Plan

Physiotherapy practice action plan
Physiotherapy practice systems action plan

Physiotherapy practice systems self audit tool
Physiotherapy practice systems self-audit tool for physiotherapists to use at their practice.

Physiotherapy restricted consultation application form
This application form needs to be completed if a physiotherapist is looking to undertake a restricted consultation.

Pre-injury employment durable return to work certificate template
Pre-injury employment durable return to work certificate template.

Psychology management plan
This management plan is intended to be a tool for you to review and discuss the progress of your treatment with your patient.

Recovery and return to work plan.pdf
A recovery/return to work plan is to be developed if you are likely to be away from work for more than four weeks.

Remuneration worksheet
This remuneration worksheet will assist you to calculate remuneration prior to completing your employer remuneration return.

Request for repair or replacement of a hearing aid
Request for repair or replacement of hearing aid form.

Return to work coordinator appointment and change of details form
Complete this form to appoint or change the details of your Return to Work Coordinator. All businesses in South Australia who employ 30 or more workers are required to appoint and retain a trained return to work coordinator.

Return to Work Coordinator Appointment Form
Complete this form to appoint a return to work coordinator.

RISE Job vacancy information and approval form
Re-employment incentive scheme for employers (RISE) - Job vacancy information and approval form.

RISE Wage reimbursement request form
Re-employment incentive scheme for employers (RISE) - Wage reimbursement request form

Second opinion medicine referral form
Second Opinion Medicine referral form.

Section 180 application for access form
This form should be completed by workers or their representatives when they wish to access details about their claim.

Section 180 internal review application form
Please complete this form if you want to request a review of a decision regarding access to information under Section 180.

Section 185 request for exchange of information form
This form should be completed by claims agents or self insured employers when they need to exchange information about a workers' claim(s).

Self-insured - application for renewal
This document is a template that may be used when applying for renewal of registration as a self-insured employer.

Self-insured claim investigation application form
To apply for an authority under Section 183 for Self-Insured employers, please use this form.

Service provider registration form
Return to work service provider registration form.

Speech pathology management plan
Speech Pathology Management Plan

The FAB Tool - Allied health physical Functional ABility recommendation template
Allied health functional capacity recommendation template

Whole person impairment physical assessment report template
Compulsory whole person impairment physical assessment report template for accredited ReturnToWorkSA impairment assessors.

Whole person impairment psychiatric assessment report template
Compulsory whole person impairment psychiatric assessment report template for accredited ReturnToWorkSA impairment assessors.

Work capacity certificate
The work capacity certificate is an important tool for documenting a medical assessment of a patient's injury and their capacity to return to work.