Claim Form - Return To Work - Government Of South Australia Page 2
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4Section 1 - About this claim
Section 3 - Injury details
1A - What is the claim for?
3A - Injury information
Loss of wages
Medical expenses
What was the circumstance in which the injury occurred?
Loss of wages and medical expenses
(tick one) while:
Working at usual workplace
1B - Who is filling out this form?
Working, had a traffic accident—Police Report Number:
When possible, it is suggested the worker and employer complete this
Having a break
form together.
Travelling to or from work
Worker
Employer
Attending an approved course of study
Both worker and employer completing the form together
Working elsewhere
Other - Name:
________________________________________
Other (please specify):
__________________________________
Relationship (i.e. Family, friend or representative):
____________
____________________________________________________
Date and time of the injury: (or when was it first noticed)
Phone
______________________________________________
Date
Time
:
am
Did the worker stop work due to the injury?
Yes
No
Section 2 - Worker details
If yes, date and time work was stopped:
Date
Time
am
Family name:
_____________________________________________
Given names:
_____________________________________________
Has the worker resumed work?
Yes
No
Former names
:
_______________________________________
(if any)
If yes, date and time worker resumed:
Title:
Miss
Ms
Mrs
Mr
Date
Time
am
Date of birth:
Has the worker returned to:
Gender:
M
F
Other
pre-injury hours or
less than pre-injury hours
Address:
_________________________________________________
Has the worker returned to:
________________________________________________________
normal duties or
modified duties
Postal address
:
______________________
(or if same write ‘same as above’)
3B - Where did the injury occur?
________________________________________________________
Place
:
_____________________________________
(e.g. workshop floor)
Daytime phone number:
____________________________________
Address:
_________________________________________________
Mobile number:
___________________________________________
Suburb / town: _____________________Postcode:
______________
Email:___________________________________________________
(Note: Providing an email will ensure prompt receipt of important notices.)
3C - Description of the injury
Does the worker wish to identify as:
What is the injury and part of the body affected? (e.g. broken left lower
Aboriginal
Torres Strait Islander
leg, dermatitis of the hands, lower back strain):
Country of birth:
__________________________________________
Does the worker need an interpreter?:
Yes
No
What was the worker doing at the time of the injury? (e.g. lifting bags of
If yes, identify language
_________________________
(including Auslan):
cement from pallet to trolley):
Dialect
__________________________________________________
:
Is the worker an Australian citizen or permanent resident of Australia?
Yes
No
If ‘No’
___________________________________________________
:
What happened and how was worker injured? (e.g. repeatedly lifting
Type of visa
______________________________________________
:
heavy bags causing lower back pain):
Expiry date
:
*Throughout this form ‘injury’ should be read as
‘work related illness, condition or injury’
Page 2 of 4
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