Safety, Rehabilitation and Compensation Act 1988 - sections 34K and 34S - Approved Form for Application for Renewal of Approval as a Rehabilitation Program Provider (29/09/2006)

COMMONWEALTH OF AUSTRALIA

Safety, Rehabilitation and Compensation Act 1988

SECTIONS 34K and 34S

APPROVED FORM FOR APPLICATION FOR RENEWAL OF APPROVAL AS A REHABILITATION PROGRAM PROVIDER

Comcare, pursuant to paragraph 34K(1)(a) and subsection 34S(1) of the Safety, Rehabilitation and Compensation Act 1988, approves the following form as the approved form for the purposes of persons applying under section 34J for renewal of approval as a rehabilitation program provider. This approval applies on and from 1 November 2006.

Dated 29 September 2006

The seal of Comcare was affixed
in the presence of:

Barbara Bennett
Chief Executive Officer

Renewal Application Form pages 1- 13 attached

Safety, Rehabilitation and Compensation Act 1988

APPLICATION FORM

FOR

RENEWAL OF APPROVAL

AS A

REHABILITATION PROGRAM PROVIDER

This application form is an approved form for the purposes of section 34S of the Safety, Rehabilitation and Compensation Act 1988 and is to be completed by approved rehabilitation providers seeking renewal of approval under sections 34J and 34K of the Act.

INFORMATION ON COMPLETING
THE RENEWAL APPLICATION

1. Approved Rehabilitation Providers (providers) may apply to Comcare for renewal of approval as a rehabilitation program provider. The application must be in writing in the approved form and be accompanied by the prescribed fee.
2. The renewal process is a combination of self assessment and comparative performance measurement based on Comcare’s Criteria for Initial Approval or Renewal of Approval of Rehabilitation Program Providers (the criteria) and Comcare’s Operational Standards for Rehabilitation Program Providers (the standards). The standards consist of both outcome standards and service standards.
3. Comcare will renew the approval of the provider under section 34L of the Safety, Rehabilitation and Compensation Act 1988 (the SRC Act) where Comcare is satisfied that the provider:

(a) meets the criteria

(b) has demonstrated compliance with the standards in force since the applicant was initially approved or last renewed, and

(c) is likely to meet the standards in force with effect from the renewal date.

The renewal process

4. There are three stages in the renewal process:

(a) provider completes the application for renewal (including the self-assessment tool)

(b) Comcare assesses the application and the provider’s performance against Comcare’s operational standards, and

(c) Comcare issues a written decision renewing, renewing with conditions or refusing to renew the provider’s approval.

The provider application

5. Complete Section 1 furnishing your correct entity details.

6. Complete Part One which examines whether the provider continues to meet Comcare’s existing criteria for approval, furnishing any required documentation.

7. Part Two of the application requires the provider to conduct a self assessment of five SRC Act cases or 10 per cent of their total caseload, whichever is greater to test compliance with the Comcare’s current service standards. Comcare randomly selects the cases for assessment from the provider’s return to work plans that have been closed during the relevant period.

8. This part also requires providers to describe aspects of their return to work process or those processes they plan to adopt to meet new service standards in force from 1 July 2007, the renewal date.

9. Throughout this process Comcare may consult with the provider and may at any time request further information in writing from the provider.

Lodgement of application form

10. The provider should lodge the application or advise that they do not wish to seek renewal by 1 December 2006. Comcare will accept applications where the applicant can provide proof of lodgement by post prior to 31 December 2006. Comcare will acknowledge receipt of the application in writing.

11. Late applications may only be considered in exceptional circumstances [see s34J(3) of the SRC Act].

Integrity of the renewal process

12. To ensure the integrity of the self-assessment process, Comcare may conduct audits of randomly selected providers to assess the completion of the self-assessment tool.

Outcome standards assessment

13. Comcare will conduct an assessment of each provider’s performance in respect of their current period of approval against the following outcome standards:

(a) return to work rate (as a percentage)

(b) median cost of return to work plans (in dollars), and

(c) median duration of return to work plans (in weeks).

14. Benchmark outcome standards for each of these standards have been determined by Comcare. The outcome standards are published on Comcare’s website and are available in the publication ‘Standards for Approved Rehabilitation Providers’.

15. Comcare will calculate each provider’s RTW rate, cost and duration based on all closed return to work plans for the relevant period. The results will then be assessed for compliance against each standard’s performance measure.

Service standards assessment

16. Comcare will examine the provider’s record of meeting the current service standards through the provider’s self assessment of compliance (which may be subject to random audit by Comcare) based on a nominated sample of files. Comcare will also examine the provider’s description of its return to work processes to form a view on whether it will be likely to meet the operational standards in force from the renewal date, 1 July 2007.

Where a provider has failed to meet a standard

17. If a provider identifies poor performance against a standard during the self-assessment process, the provider must attach an explanatory statement at the time of submitting the application. Comcare considers performance by a provider against each individual standard within the context of overall performance against all standards.

18. Factors which may be considered include servicing remote areas, managing complex injuries, assisting with redeployment and late intervention cases.

Renewal of approval

19. If Comcare is satisfied, having regard to the information in the application, or any additional information supplied, that the provider meets the application criteria and has demonstrated compliance with the operational standards in force since the provider was initially approved or last renewed and is likely to meet the operational standards from the renewal period, it will renew the approval of the provider for a period of three years and inform the provider of its decision in writing.

20. Comcare may also grant a conditional renewal of approval. The provider would be advised of the conditions and their review rights in writing.

21. If Comcare refuses to renew the applicant’s approval, the provider will be advised of the reasons and their review rights in writing.

Section 1 – Application form for renewal of approval as a rehabilitation program provider

<table cellspacing="0" cellpadding="0" style="border:0.75pt solid #000000; border-collapse:collapse"><tbody><tr><td colspan="5" style="border-bottom:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top; background-color:#c0c0c0"><p style="font-size:11pt"><span style="font-family:'Arial Narrow', sans-serif">If you </span><span style="font-family:'Arial Narrow', sans-serif; font-weight:bold">WISH TO SEEK RENEWAL</span><span style="font-family:'Arial Narrow', sans-serif; font-weight:bold"> </span><span style="font-family:'Arial Narrow', sans-serif">please fill out the details below</span><span style="font-family:'Arial Narrow', sans-serif">. C</span><span style="font-family:'Arial Narrow', sans-serif">omplete the application and return it to Comcare by </span><span style="font-family:'Arial Narrow', sans-serif; font-weight:bold">1 December 2006</span><span style="font-family:'Arial Narrow', sans-serif">.</span></p></td></tr><tr style="height:28.35pt"><td style="width:162.6pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:middle"><p style="font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif; font-weight:bold">Name of Approved Rehabilitation Provider</span></p></td><td colspan="4" style="width:265.65pt; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:middle"><p style="font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td></tr><tr><td style="width:162.6pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-bottom:14pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif; font-weight:bold">What is your Australian Business Number (ABN)?</span><span style="font-family:'Arial Narrow', sans-serif; font-weight:bold"></span></p><p style="margin-top:14pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif; font-weight:bold">And does this match with your approved entity status with Comcare?</span></p></td><td colspan="4" style="width:265.65pt; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-bottom:14pt; font-size:10pt"><br><span style="font-family:'Arial Narrow', sans-serif"></span></p><p style="margin-top:14pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif">Attach copy of the AB</span><span style="font-family:'Arial Narrow', sans-serif">N</span><span style="font-family:'Arial Narrow', sans-serif"> record</span><span style="font-family:'Arial Narrow', sans-serif"> from the Australian Business Registry</span><span style="font-family:'Arial Narrow', sans-serif">.</span><span style="font-family:'Arial Narrow', sans-serif"> </span><span style="font-family:'Arial Narrow', sans-serif; font-size:8pt; font-style:italic">Go to </span><a href="http://www.abr.business.gov.au" style="text-decoration:none"><span class="Hyperlink" style="font-family:'Arial Narrow', sans-serif; font-size:8pt; font-style:italic">www.abr.business.gov.au</span></a><span style="font-family:'Arial Narrow', sans-serif; font-size:8pt; font-style:italic"> to find your ABN record.</span></p></td></tr><tr style="height:5.7pt"><td rowspan="4" style="width:162.6pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-bottom:14pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif; font-weight:bold">What is your Comcare approved rehabilitation provider number/s?</span></p><p style="margin-top:14pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif; font-weight:bold"></span></p></td><td style="width:67.9pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif">ACT</span></p></td><td style="width:64.95pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:36.6pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif">SA</span></p></td><td style="width:63.8pt; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td></tr><tr style="height:5.7pt"><td style="width:67.9pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif">NSW</span></p></td><td style="width:64.95pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:36.6pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif">WA</span></p></td><td style="width:63.8pt; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td></tr><tr style="height:5.7pt"><td style="width:67.9pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif">QLD</span></p></td><td style="width:64.95pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:36.6pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif">NT</span></p></td><td style="width:63.8pt; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td></tr><tr style="height:5.7pt"><td style="width:67.9pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif">VIC</span></p></td><td style="width:64.95pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:36.6pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif">TAS</span></p></td><td style="width:63.8pt; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td></tr></tbody></table>

<table cellspacing="0" cellpadding="0" style="border:0.75pt solid #000000; border-collapse:collapse"><tbody><tr><td colspan="5" style="border-bottom:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top; background-color:#c0c0c0"><p style="font-size:11pt"><span style="font-family:'Arial Narrow', sans-serif">If you </span><span style="font-family:'Arial Narrow', sans-serif; font-weight:bold">DO NOT</span><span style="font-family:'Arial Narrow', sans-serif"> </span><span style="font-family:'Arial Narrow', sans-serif; font-weight:bold">WISH TO SEEK RENEWAL</span><span style="font-family:'Arial Narrow', sans-serif; font-weight:bold"> </span><span style="font-family:'Arial Narrow', sans-serif">please fill out the details below</span><span style="font-family:'Arial Narrow', sans-serif"> and send only this page to Comcare. Fax 02 6221 5564 or</span><span style="font-family:'Arial Narrow', sans-serif"> </span><span style="font-family:'Arial Narrow', sans-serif">to the address stated below </span><span style="font-family:'Arial Narrow', sans-serif">by </span><span style="font-family:'Arial Narrow', sans-serif; font-weight:bold">1 December 2006</span><span style="font-family:'Arial Narrow', sans-serif">.</span></p></td></tr><tr><td colspan="5" style="border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="font-size:20pt"><span style="font-family:'Arial Narrow', sans-serif; font-size:10pt; font-weight:bold">Not seeking renewal of approval</span><span style="font-family:'Arial Narrow', sans-serif; font-size:10pt; font-weight:bold"> </span><span style="font-family:'Arial Narrow', sans-serif; font-size:10pt; font-weight:bold">(please tick) </span><span style="font-family:'Arial Narrow', sans-serif; font-weight:bold">□</span><span style="font-family:'Arial Narrow', sans-serif; font-size:10pt; font-weight:bold"></span></p></td></tr><tr style="height:17.5pt"><td style="width:195.45pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif; font-weight:bold">Name of Approved Rehabilitation Provider</span></p></td><td colspan="4" style="width:232.8pt; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td></tr><tr style="height:5.7pt"><td rowspan="4" style="width:195.45pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-bottom:14pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif; font-weight:bold">What is your Comcare approved rehabilitation provider number/s?</span></p><p style="margin-top:14pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif; font-weight:bold"></span></p></td><td style="width:34.35pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif">ACT</span></p></td><td style="width:67.75pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:42.4pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif">SA</span></p></td><td style="width:55.9pt; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td></tr><tr style="height:5.7pt"><td style="width:34.35pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif">NSW</span></p></td><td style="width:67.75pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:42.4pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif">WA</span></p></td><td style="width:55.9pt; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td></tr><tr style="height:5.7pt"><td style="width:34.35pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif">QLD</span></p></td><td style="width:67.75pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:42.4pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif">NT</span></p></td><td style="width:55.9pt; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td></tr><tr style="height:5.7pt"><td style="width:34.35pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif">VIC</span></p></td><td style="width:67.75pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:42.4pt; border:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif">TAS</span></p></td><td style="width:55.9pt; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td></tr><tr><td style="width:195.45pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif; font-weight:bold">Business address – postal</span></p></td><td colspan="4" style="width:232.8pt; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td></tr><tr><td style="width:195.45pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif; font-weight:bold">Your name and title</span></p></td><td colspan="4" style="width:232.8pt; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td></tr><tr><td style="width:195.45pt; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif; font-weight:bold">Signature</span></p></td><td colspan="4" style="width:232.8pt; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td></tr></tbody></table>

Please return to: Approved Rehabilitation Providers – Renewal

Comcare

GPO Box 9905, Canberra ACT 2601

Complete the following questions in relation to you as a provider since 1 July 2004 (or from the date of your initial approval if after 1 July 2004):

You are reminded that giving false or misleading information is a serious offence under the Criminal Code.

Criterion 1 – Competence

1. Has the provider advised Comcare in writing of all individuals employed or engaged by the provider to manage return to work plans under the SRC Act, including evidence of qualifications and experience?

If no, provide an explanation and include the names of those individuals, attaching all relevant documentation.

Yes

Criterion 2: Probity

2. Has the provider, its principals or employees been refused approval as a provider of rehabilitation services or had such approval withdrawn under a workers' compensation scheme in any Australian State or Territory?

No

If yes, provide details of the circumstances and reasons why there is no cause to reject the provider’s application.

3. Have proceedings in relation to professional misconduct or criminal proceedings been taken (or are pending) against the provider, a principal or an employee?

No

If yes, provide details of the circumstances and reasons why there is no cause to reject the provider’s application.

4. During the immediately preceding six years, has the provider, its principals or employees, been subject to any award of damages, or settlement (with or without admission of liability) of any negligence claim, in respect of anything done or omitted in professional practice or training?

No

If yes, provide details of the circumstances and reasons why there is no cause to reject the provider’s application.

5. Has the provider or any principal been declared bankrupt in the last seven years?

No

If yes, provide details of the circumstances and reasons why there is no cause to reject the provider’s application.

6. Has the provider, a principal or an employee been found to have breached the Racial Discrimination Act 1975, the Sex Discrimination Act 1984, the Disability Discrimination Act 1992, the Privacy Act 1988 or equivalent State and Territory legislation?

No

If yes Provide details of the circumstances and reasons why there is no cause to reject the provider’s application.

7. Is the provider currently subject to the Commonwealth Privacy Act 1988?

No

Yes

Criterion 3: Financial requirements

8. The provider attests to its financial viability with a reference from an independent, qualified person (such as an accountant or bank manager).

No

If yes, attach reference

9. There is current coverage, which is sufficient to your level of risk, for:

(a) Professional indemnity insurance for all individuals employed and engaged by the provider to provide return to work services under the SRC Act

(b) Public liability insurance for the provider, and

(c) Workers’ compensation insurance where staff are employed by the provider.

No

Yes Provide a certificate of currency disclosing the name of the insured, the name of the insurance company, type of insurance/s, amount/s insured, policy number/s, amounts and duration of the coverage.

Criterion 4: Referral base

10. Has the provider had one or more referrals to provide services as a rehabilitation program provider under the Safety, Rehabilitation and Compensation Act 1988 in the past twelve months?

No Please attach explanation.

Yes □ Australian Government or ACT Public Sector
□ Licensed self-insurer (i.e. Telstra, Australia Post)
□ Other Commonwealth schemes (Seacare or Military Rehabilitation Compensation Commission)

Criterion 5: Satisfactory evaluation of performance

Outcome Standards

11. Upon receipt of this application Comcare will assess the provider’s performance against Comcare’s Outcome Standards (return to work rate, cost and duration) for the relevant period.

Where the provider anticipates that they may have failed to meet any of the outcome standards, the provider may attach a statement explaining the circumstances.

Service Standards – Self-assessment tool

12. Having reviewed the identified files, the provider confirms compliance with each standard by placing a tick in the relevant space in the table provided in Part Two. Comcare may ask the provider to produce documentation which confirms compliance.

Where the provider has not met the relevant service standard, a statement explaining the circumstances shall be attached to the application for Comcare’s consideration.

Service Standards – Capacity to meet standards in force from 1 July 2007, the renewal date

13. Describe the provider’s management of the return to work process to address how they would identify and seek to mitigate any personal, social or environmental risk factors which may be present in more complex cases. Also describe how in cases more than 12 weeks incapacity the provider’s approach to reduce the risk of ongoing chronicity, including how they would engage treating practitioners to resolve certified medical restrictions and incorporate evidence-based medical recovery timeframes.

**Where indicated – insert dates where requested otherwise insert a tick against each standard you have complied with.

<table cellspacing="0" cellpadding="0" style="border-collapse:collapse"><thead><tr><td style="width:267.95pt; border-top:1pt solid #000000; border-bottom:1pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top; background-color:#cccccc"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif; font-weight:bold">Self-assessment criteria</span></p><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.5pt; border-top:1pt solid #000000; border-bottom:1pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top; background-color:#cccccc"><p style="margin-top:5pt; margin-bottom:5pt; text-align:center; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif; font-weight:bold">File</span></p><p style="margin-top:5pt; margin-bottom:5pt; text-align:center; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif; font-weight:bold">1</span></p></td><td style="width:29.55pt; border-top:1pt solid #000000; border-bottom:1pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top; background-color:#cccccc"><p style="margin-top:5pt; margin-bottom:5pt; text-align:center; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif; font-weight:bold">File</span></p><p style="margin-top:5pt; margin-bottom:5pt; text-align:center; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif; font-weight:bold">2</span></p></td><td style="width:29.55pt; border-top:1pt solid #000000; border-bottom:1pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top; background-color:#cccccc"><p style="margin-top:5pt; margin-bottom:5pt; text-align:center; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif; font-weight:bold">File</span></p><p style="margin-top:5pt; margin-bottom:5pt; text-align:center; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif; font-weight:bold">3</span></p></td><td style="width:29.55pt; border-top:1pt solid #000000; border-bottom:1pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top; background-color:#cccccc"><p style="margin-top:5pt; margin-bottom:5pt; text-align:center; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif; font-weight:bold">File</span></p><p style="margin-top:5pt; margin-bottom:5pt; text-align:center; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif; font-weight:bold">4</span></p></td><td style="width:29.55pt; border-top:1pt solid #000000; border-right:0.75pt dotted #000000; border-bottom:1pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top; background-color:#cccccc"><p style="margin-top:5pt; margin-bottom:5pt; text-align:center; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif; font-weight:bold">File</span></p><p style="margin-top:5pt; margin-bottom:5pt; text-align:center; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif; font-weight:bold">5</span></p></td></tr></thead><tbody><tr><td style="width:267.95pt; border-top:1pt solid #000000; border-right:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top; background-color:#e6e6e6"><p style="margin-top:5pt; margin-bottom:5pt; text-align:right; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif; font-weight:bold; color:#333333">Date of injury</span></p></td><td style="width:29.5pt; border-top:1pt solid #000000; border-right:0.75pt dotted #000000; border-left:0.75pt dotted #000000; border-bottom:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top; background-color:#e6e6e6"><p style="margin-top:5pt; margin-bottom:5pt; font-size:8pt"><span style="font-family:'Arial Narrow', sans-serif; font-weight:bold; color:#c0c0c0"></span></p></td><td style="width:29.55pt; border-top:1pt solid #000000; border-right:0.75pt dotted #000000; border-left:0.75pt dotted #000000; border-bottom:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top; background-color:#e6e6e6"><p style="margin-top:5pt; margin-bottom:5pt; font-size:8pt"><span style="font-family:'Arial Narrow', sans-serif; font-weight:bold; color:#c0c0c0"></span></p></td><td style="width:29.55pt; border-top:1pt solid #000000; border-right:0.75pt dotted #000000; border-left:0.75pt dotted #000000; border-bottom:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top; background-color:#e6e6e6"><p style="margin-top:5pt; margin-bottom:5pt; font-size:8pt"><span style="font-family:'Arial Narrow', sans-serif; font-weight:bold; color:#c0c0c0"></span></p></td><td style="width:29.55pt; border-top:1pt solid #000000; border-right:0.75pt dotted #000000; border-left:0.75pt dotted #000000; border-bottom:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top; background-color:#e6e6e6"><p style="margin-top:5pt; margin-bottom:5pt; font-size:8pt"><span style="font-family:'Arial Narrow', sans-serif; font-weight:bold; color:#c0c0c0"></span></p></td><td style="width:29.55pt; border-top:1pt solid #000000; border-right:0.75pt dotted #000000; border-left:0.75pt dotted #000000; border-bottom:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top; background-color:#e6e6e6"><p style="margin-top:5pt; margin-bottom:5pt; font-size:8pt"><span style="font-family:'Arial Narrow', sans-serif; font-weight:bold; color:#c0c0c0"></span></p></td></tr><tr><td style="width:267.95pt; border-right:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top; background-color:#e6e6e6"><p style="margin-top:5pt; margin-bottom:5pt; text-align:right; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif; font-weight:bold; color:#333333">Date of referral to provider</span></p></td><td style="width:29.5pt; border:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top; background-color:#e6e6e6"><p style="margin-top:5pt; margin-bottom:5pt; font-size:8pt"><span style="font-family:'Arial Narrow', sans-serif; font-weight:bold; color:#c0c0c0"></span></p></td><td style="width:29.55pt; border:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top; background-color:#e6e6e6"><p style="margin-top:5pt; margin-bottom:5pt; font-size:8pt"><span style="font-family:'Arial Narrow', sans-serif; font-weight:bold; color:#c0c0c0"></span></p></td><td style="width:29.55pt; border:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top; background-color:#e6e6e6"><p style="margin-top:5pt; margin-bottom:5pt; font-size:8pt"><span style="font-family:'Arial Narrow', sans-serif; font-weight:bold; color:#c0c0c0"></span></p></td><td style="width:29.55pt; border:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top; background-color:#e6e6e6"><p style="margin-top:5pt; margin-bottom:5pt; font-size:8pt"><span style="font-family:'Arial Narrow', sans-serif; font-weight:bold; color:#c0c0c0"></span></p></td><td style="width:29.55pt; border:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top; background-color:#e6e6e6"><p style="margin-top:5pt; margin-bottom:5pt; font-size:8pt"><span style="font-family:'Arial Narrow', sans-serif; font-weight:bold; color:#c0c0c0"></span></p></td></tr><tr><td style="width:267.95pt; border-right:0.75pt dotted #000000; border-bottom:1pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top; background-color:#e6e6e6"><p style="margin-top:5pt; margin-bottom:5pt; text-align:right; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif; font-weight:bold; color:#333333">Date of return to work (in any capacity)</span></p></td><td style="width:29.5pt; border-top:0.75pt dotted #000000; border-right:0.75pt dotted #000000; border-left:0.75pt dotted #000000; border-bottom:1pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top; background-color:#e6e6e6"><p style="margin-top:5pt; margin-bottom:5pt; font-size:8pt"><span style="font-family:'Arial Narrow', sans-serif; font-weight:bold; color:#c0c0c0"></span></p></td><td style="width:29.55pt; border-top:0.75pt dotted #000000; border-right:0.75pt dotted #000000; border-left:0.75pt dotted #000000; border-bottom:1pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top; background-color:#e6e6e6"><p style="margin-top:5pt; margin-bottom:5pt; font-size:8pt"><span style="font-family:'Arial Narrow', sans-serif; font-weight:bold; color:#c0c0c0"></span></p></td><td style="width:29.55pt; border-top:0.75pt dotted #000000; border-right:0.75pt dotted #000000; border-left:0.75pt dotted #000000; border-bottom:1pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top; background-color:#e6e6e6"><p style="margin-top:5pt; margin-bottom:5pt; font-size:8pt"><span style="font-family:'Arial Narrow', sans-serif; font-weight:bold; color:#c0c0c0"></span></p></td><td style="width:29.55pt; border-top:0.75pt dotted #000000; border-right:0.75pt dotted #000000; border-left:0.75pt dotted #000000; border-bottom:1pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top; background-color:#e6e6e6"><p style="margin-top:5pt; margin-bottom:5pt; font-size:8pt"><span style="font-family:'Arial Narrow', sans-serif; font-weight:bold; color:#c0c0c0"></span></p></td><td style="width:29.55pt; border-top:0.75pt dotted #000000; border-right:0.75pt dotted #000000; border-left:0.75pt dotted #000000; border-bottom:1pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top; background-color:#e6e6e6"><p style="margin-top:5pt; margin-bottom:5pt; font-size:8pt"><span style="font-family:'Arial Narrow', sans-serif; font-weight:bold; color:#c0c0c0"></span></p></td></tr><tr><td colspan="6" style="width:469.65pt; border-top:1pt solid #000000; border-right:0.75pt dotted #000000; border-bottom:1pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top; background-color:#cccccc"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif; font-weight:bold">Service Standard 1 – Service </span><span style="font-family:'Arial Narrow', sans-serif; font-weight:bold">p</span><span style="font-family:'Arial Narrow', sans-serif; font-weight:bold">hilosophy</span><span style="font-family:'Arial Narrow', sans-serif; font-weight:bold"></span></p></td></tr><tr><td style="width:267.95pt; border-top:1pt solid #000000; border-right:0.75pt dotted #000000; border-bottom:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif; font-weight:bold">1.3</span><span style="font-family:'Arial Narrow', sans-serif"> </span><span style="font-family:'Arial Narrow', sans-serif; font-weight:bold">Conflict of Interest</span></p><p style="margin-top:5pt; margin-bottom:5pt; text-align:right; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif">The provider ensured no conflict of interest occurred</span><span style="font-family:'Arial Narrow', sans-serif">,</span><span style="font-family:'Arial Narrow', sans-serif"> specifically treatment and occupational rehabilitation services were not provided to the same individual</span><span style="font-family:'Arial Narrow', sans-serif">.</span></p></td><td style="width:29.5pt; border-top:1pt solid #000000; border-right:0.75pt dotted #000000; border-left:0.75pt dotted #000000; border-bottom:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border-top:1pt solid #000000; border-right:0.75pt dotted #000000; border-left:0.75pt dotted #000000; border-bottom:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border-top:1pt solid #000000; border-right:0.75pt dotted #000000; border-left:0.75pt dotted #000000; border-bottom:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border-top:1pt solid #000000; border-right:0.75pt dotted #000000; border-left:0.75pt dotted #000000; border-bottom:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border-top:1pt solid #000000; border-right:0.75pt dotted #000000; border-left:0.75pt dotted #000000; border-bottom:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td></tr><tr><td style="width:267.95pt; border-top:0.75pt dotted #000000; border-right:0.75pt dotted #000000; border-bottom:1pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif; font-weight:bold">1.4</span><span style="font-family:'Arial Narrow', sans-serif; font-weight:bold"> Privacy</span></p><p style="margin-top:5pt; margin-bottom:5pt; text-align:right; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif">For the purposes of the rehabilitation process, a personal information release authority was obtained and the employee was advised of their privacy rights.</span></p></td><td style="width:29.5pt; border-top:0.75pt dotted #000000; border-right:0.75pt dotted #000000; border-left:0.75pt dotted #000000; border-bottom:1pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border-top:0.75pt dotted #000000; border-right:0.75pt dotted #000000; border-left:0.75pt dotted #000000; border-bottom:1pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border-top:0.75pt dotted #000000; border-right:0.75pt dotted #000000; border-left:0.75pt dotted #000000; border-bottom:1pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border-top:0.75pt dotted #000000; border-right:0.75pt dotted #000000; border-left:0.75pt dotted #000000; border-bottom:1pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border-top:0.75pt dotted #000000; border-right:0.75pt dotted #000000; border-left:0.75pt dotted #000000; border-bottom:1pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td></tr><tr><td colspan="6" style="width:469.65pt; border-top:1pt solid #000000; border-right:0.75pt dotted #000000; border-bottom:1pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top; background-color:#cccccc"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif; font-weight:bold">Service Standard 2 – Return to </span><span style="font-family:'Arial Narrow', sans-serif; font-weight:bold">w</span><span style="font-family:'Arial Narrow', sans-serif; font-weight:bold">ork </span><span style="font-family:'Arial Narrow', sans-serif; font-weight:bold">m</span><span style="font-family:'Arial Narrow', sans-serif; font-weight:bold">anagement</span></p></td></tr><tr><td colspan="6" style="width:469.65pt; border-top:1pt solid #000000; border-right:0.75pt dotted #000000; border-bottom:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.4pt"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif; font-weight:bold">2.1 Timely acknowledgement</span></p></td></tr><tr style="height:28.35pt"><td style="width:267.95pt; border-top:0.75pt dotted #000000; border-right:0.75pt dotted #000000; border-bottom:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.4pt"><p style="text-align:right; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif">Date of contact with case manager to acknowledge receipt of referral for assessment.</span></p></td><td style="width:29.5pt; border:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td></tr><tr><td colspan="6" style="width:469.65pt; border-top:0.75pt dotted #000000; border-right:0.75pt dotted #000000; border-bottom:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.4pt"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif; font-weight:bold">2.2 Ensure contact is made with all key parties within three working days</span></p></td></tr><tr style="height:28.35pt"><td style="width:267.95pt; border-top:0.75pt dotted #000000; border-right:0.75pt dotted #000000; border-bottom:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.4pt"><p style="text-align:right; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif">Date of contact with employee.</span></p></td><td style="width:29.5pt; border:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td></tr><tr style="height:28.35pt"><td style="width:267.95pt; border-top:0.75pt dotted #000000; border-right:0.75pt dotted #000000; border-bottom:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.4pt"><p style="text-align:right; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif">Date of initial contact with supervisor.</span></p></td><td style="width:29.5pt; border:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td></tr><tr style="height:28.35pt"><td style="width:267.95pt; border-top:0.75pt dotted #000000; border-right:0.75pt dotted #000000; border-bottom:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.4pt"><p style="text-align:right; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif">Date of contact with medical practitioner.</span></p></td><td style="width:29.5pt; border:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td></tr><tr><td colspan="6" style="width:469.65pt; border-top:0.75pt dotted #000000; border-right:0.75pt dotted #000000; border-bottom:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.4pt"><p style="margin-top:2pt; margin-bottom:2pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif; font-weight:bold">2.3</span><span style="font-family:'Arial Narrow', sans-serif; font-weight:bold"> Assessment services undertaken within 10 working days</span></p></td></tr><tr style="height:28.35pt"><td style="width:267.95pt; border-top:0.75pt dotted #000000; border-right:0.75pt dotted #000000; border-bottom:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.4pt"><p style="text-align:right; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif">Date of workplace visit.</span></p></td><td style="width:29.5pt; border:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td></tr><tr style="height:28.35pt"><td style="width:267.95pt; border-top:0.75pt dotted #000000; border-right:0.75pt dotted #000000; border-bottom:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.4pt"><p style="text-align:right; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif">Date of completion of initial assessment report.</span></p></td><td style="width:29.5pt; border:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td></tr><tr style="height:28.35pt"><td style="width:267.95pt; border-top:0.75pt dotted #000000; border-right:0.75pt dotted #000000; border-bottom:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.4pt"><p style="text-align:right; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif">Date referring authority advised of outcome of initial assessment.</span></p></td><td style="width:29.5pt; border:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td></tr><tr style="height:28.35pt"><td style="width:267.95pt; border-top:0.75pt dotted #000000; border-right:0.75pt dotted #000000; border-bottom:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.4pt"><p style="text-align:right; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif">Initial assessment of the employee’s capability of undertaking a rehabilitation program was completed within ten </span><span style="font-family:'Arial Narrow', sans-serif">working </span><span style="font-family:'Arial Narrow', sans-serif">days of receipt of a referral for assessment</span></p></td><td style="width:29.5pt; border:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td></tr><tr style="height:28.35pt"><td style="width:267.95pt; border-top:0.75pt dotted #000000; border-right:0.75pt dotted #000000; border-bottom:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.4pt"><p style="text-align:right; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif">The referring rehabilitation authority advised of the outcome of the initial assessment within ten working days of a referral for assessment</span></p></td><td style="width:29.5pt; border:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td></tr><tr style="height:28.35pt"><td style="width:267.95pt; border-top:0.75pt dotted #000000; border-right:0.75pt dotted #000000; border-bottom:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.4pt"><p style="text-align:right; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif">Cost of initial rehabilitation assessment</span></p></td><td style="width:29.5pt; border:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td></tr><tr><td colspan="6" style="width:469.65pt; border-top:0.75pt dotted #000000; border-right:0.75pt dotted #000000; border-bottom:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.4pt"><p style="margin-top:2pt; margin-bottom:2pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif; font-weight:bold">2.4 </span><span style="font-family:'Arial Narrow', sans-serif; font-weight:bold">Return to Work plan</span></p></td></tr><tr style="height:28.35pt"><td style="width:267.95pt; border-top:0.75pt dotted #000000; border-right:0.75pt dotted #000000; border-bottom:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.4pt"><p style="margin-top:5pt; margin-bottom:5pt; text-align:right; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif">As soon as possible after the assessment was completed, a </span><span style="font-family:'Arial Narrow', sans-serif">return to work</span><span style="font-family:'Arial Narrow', sans-serif"> </span><span style="font-family:'Arial Narrow', sans-serif">p</span><span style="font-family:'Arial Narrow', sans-serif">lan was developed, negotiated with and approved by the referring rehabilitation authority</span><span style="font-family:'Arial Narrow', sans-serif">.</span></p></td><td style="width:29.5pt; border:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td></tr><tr style="height:28.35pt"><td style="width:267.95pt; border-top:0.75pt dotted #000000; border-right:0.75pt dotted #000000; border-bottom:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.4pt"><p style="font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif">Date </span><span style="font-family:'Arial Narrow', sans-serif">of </span><span style="font-family:'Arial Narrow', sans-serif">Return to Work Plan</span></p></td><td style="width:29.5pt; border:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt"><p style="font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif; font-style:italic"></span></p></td><td style="width:29.55pt; border:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt"><p style="font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif; font-style:italic"></span></p></td><td style="width:29.55pt; border:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt"><p style="font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif; font-style:italic"></span></p></td><td style="width:29.55pt; border:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt"><p style="font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif; font-style:italic"></span></p></td><td style="width:29.55pt; border:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt"><p style="font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif; font-style:italic"></span></p></td></tr></tbody></table>

<table cellspacing="0" cellpadding="0" style="border-collapse:collapse"><tbody><tr><td colspan="6" style="width:469.65pt; border-right:0.75pt dotted #000000; border-bottom:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif; font-weight:bold">2.5</span><span style="font-family:'Arial Narrow', sans-serif"> </span><span style="font-family:'Arial Narrow', sans-serif">Return to </span><span style="font-family:'Arial Narrow', sans-serif">The </span><span style="font-family:'Arial Narrow', sans-serif">return to work</span><span style="font-family:'Arial Narrow', sans-serif"> </span><span style="font-family:'Arial Narrow', sans-serif">p</span><span style="font-family:'Arial Narrow', sans-serif">lan detailed the:</span></p></td></tr><tr><td style="width:267.95pt; border-top:0.75pt dotted #000000; border-right:0.75pt dotted #000000; border-bottom:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:5pt; margin-left:46.35pt; margin-bottom:5pt; text-indent:-10.35pt; text-align:right; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif">G</span><span style="font-family:'Arial Narrow', sans-serif">oals</span></p></td><td style="width:29.5pt; border:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td></tr><tr><td style="width:267.95pt; border-top:0.75pt dotted #000000; border-right:0.75pt dotted #000000; border-bottom:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:5pt; margin-left:46.35pt; margin-bottom:5pt; text-indent:-10.35pt; text-align:right; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif">R</span><span style="font-family:'Arial Narrow', sans-serif">oles and responsibilities</span></p></td><td style="width:29.5pt; border:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td></tr><tr><td style="width:267.95pt; border-top:0.75pt dotted #000000; border-right:0.75pt dotted #000000; border-bottom:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:5pt; margin-left:46.35pt; margin-bottom:5pt; text-indent:-10.35pt; text-align:right; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif">N</span><span style="font-family:'Arial Narrow', sans-serif">ature of interventions</span></p></td><td style="width:29.5pt; border:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td></tr><tr><td style="width:267.95pt; border-top:0.75pt dotted #000000; border-right:0.75pt dotted #000000; border-bottom:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:5pt; margin-left:46.35pt; margin-bottom:5pt; text-indent:-10.35pt; text-align:right; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif">C</span><span style="font-family:'Arial Narrow', sans-serif">osts</span></p></td><td style="width:29.5pt; border:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td></tr><tr><td style="width:267.95pt; border-top:0.75pt dotted #000000; border-right:0.75pt dotted #000000; border-bottom:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:5pt; margin-left:46.35pt; margin-bottom:5pt; text-indent:-10.35pt; text-align:right; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif">E</span><span style="font-family:'Arial Narrow', sans-serif">xpected duration of the plan</span></p></td><td style="width:29.5pt; border:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td></tr><tr><td style="width:267.95pt; border-top:0.75pt dotted #000000; border-right:0.75pt dotted #000000; border-bottom:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif; font-weight:bold">2.7</span><span style="font-family:'Arial Narrow', sans-serif"> There was consultation with treating health professionals and other relevant medical providers to ensure the plan was consistent with medical advice.</span></p></td><td style="width:29.5pt; border:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td></tr><tr><td colspan="6" style="width:469.65pt; border-top:0.75pt dotted #000000; border-right:0.75pt dotted #000000; border-bottom:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif; font-weight:bold">2.8</span><span style="font-family:'Arial Narrow', sans-serif"> The </span><span style="font-family:'Arial Narrow', sans-serif">return to work</span><span style="font-family:'Arial Narrow', sans-serif"> </span><span style="font-family:'Arial Narrow', sans-serif">p</span><span style="font-family:'Arial Narrow', sans-serif">lan:</span></p></td></tr><tr><td style="width:267.95pt; border-top:0.75pt dotted #000000; border-right:0.75pt dotted #000000; border-bottom:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:5pt; margin-left:46.35pt; margin-bottom:5pt; text-indent:-10.35pt; text-align:right; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif">W</span><span style="font-family:'Arial Narrow', sans-serif">orkplace based</span></p></td><td style="width:29.5pt; border:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td></tr><tr><td style="width:267.95pt; border-top:0.75pt dotted #000000; border-right:0.75pt dotted #000000; border-bottom:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:5pt; margin-left:46.35pt; margin-bottom:5pt; text-indent:-10.35pt; text-align:right; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif">I</span><span style="font-family:'Arial Narrow', sans-serif">ncluded worksite program monitoring</span></p></td><td style="width:29.5pt; border:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td></tr><tr><td style="width:267.95pt; border-top:0.75pt dotted #000000; border-right:0.75pt dotted #000000; border-bottom:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:5pt; margin-left:46.35pt; margin-bottom:5pt; text-indent:-10.35pt; text-align:right; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif">I</span><span style="font-family:'Arial Narrow', sans-serif">ncluded review meetings with key parties</span></p></td><td style="width:29.5pt; border:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td></tr><tr><td style="width:267.95pt; border-top:0.75pt dotted #000000; border-right:0.75pt dotted #000000; border-bottom:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif; font-weight:bold">2.1</span><span style="font-family:'Arial Narrow', sans-serif; font-weight:bold">2</span><span style="font-family:'Arial Narrow', sans-serif"> Employee contacted prior to a decision to recommend that the </span><span style="font-family:'Arial Narrow', sans-serif">return to work</span><span style="font-family:'Arial Narrow', sans-serif"> </span><span style="font-family:'Arial Narrow', sans-serif">p</span><span style="font-family:'Arial Narrow', sans-serif">lan </span><span style="font-family:'Arial Narrow', sans-serif">be closed.</span></p></td><td style="width:29.5pt; border:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td></tr><tr><td style="width:267.95pt; border-top:0.75pt dotted #000000; border-right:0.75pt dotted #000000; border-bottom:1pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif; font-weight:bold">2.1</span><span style="font-family:'Arial Narrow', sans-serif; font-weight:bold">3</span><span style="font-family:'Arial Narrow', sans-serif"> </span><span style="font-family:'Arial Narrow', sans-serif">Feedback sought from the referring rehabilitation authority regarding level of satisfaction with the outcome of the return to work plan and the nature of services provided</span><span style="font-family:'Arial Narrow', sans-serif">.</span></p></td><td style="width:29.5pt; border-top:0.75pt dotted #000000; border-right:0.75pt dotted #000000; border-left:0.75pt dotted #000000; border-bottom:1pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border-top:0.75pt dotted #000000; border-right:0.75pt dotted #000000; border-left:0.75pt dotted #000000; border-bottom:1pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border-top:0.75pt dotted #000000; border-right:0.75pt dotted #000000; border-left:0.75pt dotted #000000; border-bottom:1pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border-top:0.75pt dotted #000000; border-right:0.75pt dotted #000000; border-left:0.75pt dotted #000000; border-bottom:1pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border-top:0.75pt dotted #000000; border-right:0.75pt dotted #000000; border-left:0.75pt dotted #000000; border-bottom:1pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td></tr><tr><td colspan="6" style="width:469.65pt; border-top:1pt solid #000000; border-right:0.75pt dotted #000000; border-bottom:1pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top; background-color:#cccccc"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif; font-weight:bold">Service Standard 3 – Suitable and </span><span style="font-family:'Arial Narrow', sans-serif; font-weight:bold">d</span><span style="font-family:'Arial Narrow', sans-serif; font-weight:bold">urable </span><span style="font-family:'Arial Narrow', sans-serif; font-weight:bold">e</span><span style="font-family:'Arial Narrow', sans-serif; font-weight:bold">mployment</span><span style="font-family:'Arial Narrow', sans-serif"></span></p></td></tr><tr><td style="width:267.95pt; border-top:1pt solid #000000; border-right:0.75pt dotted #000000; border-bottom:1pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif; font-weight:bold">3.1</span><span style="font-family:'Arial Narrow', sans-serif"> The provider approached the return to work in line with the Comcare return to work hierarchy.</span></p></td><td style="width:29.5pt; border-top:1pt solid #000000; border-right:0.75pt dotted #000000; border-left:0.75pt dotted #000000; border-bottom:1pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border-top:1pt solid #000000; border-right:0.75pt dotted #000000; border-left:0.75pt dotted #000000; border-bottom:1pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border-top:1pt solid #000000; border-right:0.75pt dotted #000000; border-left:0.75pt dotted #000000; border-bottom:1pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border-top:1pt solid #000000; border-right:0.75pt dotted #000000; border-left:0.75pt dotted #000000; border-bottom:1pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border-top:1pt solid #000000; border-right:0.75pt dotted #000000; border-left:0.75pt dotted #000000; border-bottom:1pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td></tr><tr><td colspan="6" style="width:469.65pt; border-top:1pt solid #000000; border-right:0.75pt dotted #000000; border-bottom:1pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top; background-color:#cccccc"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif; font-weight:bold">Service Standard 4 – Staffing</span><span style="font-family:'Arial Narrow', sans-serif"></span></p></td></tr><tr><td style="width:267.95pt; border-top:1pt solid #000000; border-right:0.75pt dotted #000000; border-bottom:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif; font-weight:bold">4.1</span><span style="font-family:'Arial Narrow', sans-serif"> The staff member or contractor managing the </span><span style="font-family:'Arial Narrow', sans-serif">return to work plan</span><span style="font-family:'Arial Narrow', sans-serif"> meets </span><span style="font-family:'Arial Narrow', sans-serif">the competency requirements of criterion 1.</span></p></td><td style="width:29.5pt; border-top:1pt solid #000000; border-right:0.75pt dotted #000000; border-left:0.75pt dotted #000000; border-bottom:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border-top:1pt solid #000000; border-right:0.75pt dotted #000000; border-left:0.75pt dotted #000000; border-bottom:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border-top:1pt solid #000000; border-right:0.75pt dotted #000000; border-left:0.75pt dotted #000000; border-bottom:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border-top:1pt solid #000000; border-right:0.75pt dotted #000000; border-left:0.75pt dotted #000000; border-bottom:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border-top:1pt solid #000000; border-right:0.75pt dotted #000000; border-left:0.75pt dotted #000000; border-bottom:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td></tr><tr><td style="width:267.95pt; border-top:0.75pt dotted #000000; border-right:0.75pt dotted #000000; border-bottom:1pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif; font-weight:bold">4.</span><span style="font-family:'Arial Narrow', sans-serif; font-weight:bold">2</span><span style="font-family:'Arial Narrow', sans-serif"> The staff member or contractor managing the </span><span style="font-family:'Arial Narrow', sans-serif">return to work plan</span><span style="font-family:'Arial Narrow', sans-serif"> has completed the Comcare training for approved rehabilitation providers or was enrolled in the next program.</span></p></td><td style="width:29.5pt; border-top:0.75pt dotted #000000; border-right:0.75pt dotted #000000; border-left:0.75pt dotted #000000; border-bottom:1pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border-top:0.75pt dotted #000000; border-right:0.75pt dotted #000000; border-left:0.75pt dotted #000000; border-bottom:1pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border-top:0.75pt dotted #000000; border-right:0.75pt dotted #000000; border-left:0.75pt dotted #000000; border-bottom:1pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border-top:0.75pt dotted #000000; border-right:0.75pt dotted #000000; border-left:0.75pt dotted #000000; border-bottom:1pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border-top:0.75pt dotted #000000; border-right:0.75pt dotted #000000; border-left:0.75pt dotted #000000; border-bottom:1pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td></tr><tr><td colspan="6" style="width:469.65pt; border-top:1pt solid #000000; border-right:0.75pt dotted #000000; border-bottom:1pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top; background-color:#cccccc"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif; font-weight:bold">Service Standard 5 – Administrative/</span><span style="font-family:'Arial Narrow', sans-serif; font-weight:bold">f</span><span style="font-family:'Arial Narrow', sans-serif; font-weight:bold">inancial responsibilit</span><span style="font-family:'Arial Narrow', sans-serif; font-weight:bold">ies</span></p></td></tr><tr><td style="width:267.95pt; border-top:1pt solid #000000; border-right:0.75pt dotted #000000; border-bottom:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif; font-weight:bold">5.2</span><span style="font-family:'Arial Narrow', sans-serif"> The staff member or contractor managing the </span><span style="font-family:'Arial Narrow', sans-serif">return to work plan</span><span style="font-family:'Arial Narrow', sans-serif"> was covered by professional indemnity insurance.</span></p></td><td style="width:29.5pt; border-top:1pt solid #000000; border-right:0.75pt dotted #000000; border-left:0.75pt dotted #000000; border-bottom:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border-top:1pt solid #000000; border-right:0.75pt dotted #000000; border-left:0.75pt dotted #000000; border-bottom:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border-top:1pt solid #000000; border-right:0.75pt dotted #000000; border-left:0.75pt dotted #000000; border-bottom:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border-top:1pt solid #000000; border-right:0.75pt dotted #000000; border-left:0.75pt dotted #000000; border-bottom:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border-top:1pt solid #000000; border-right:0.75pt dotted #000000; border-left:0.75pt dotted #000000; border-bottom:0.75pt dotted #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td></tr><tr><td style="width:267.95pt; border-top:0.75pt dotted #000000; border-right:0.75pt dotted #000000; border-bottom:1pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif; font-weight:bold">5.</span><span style="font-family:'Arial Narrow', sans-serif; font-weight:bold">4</span><span style="font-family:'Arial Narrow', sans-serif"> </span><span style="font-family:'Arial Narrow', sans-serif">Invoices show </span><span style="font-family:'Arial Narrow', sans-serif">service description</span><span style="font-family:'Arial Narrow', sans-serif">, date of service, name of </span><span style="font-family:'Arial Narrow', sans-serif">claimant/employee</span><span style="font-family:'Arial Narrow', sans-serif">, name of employer</span><span style="font-family:'Arial Narrow', sans-serif">,</span><span style="font-family:'Arial Narrow', sans-serif"> Comcare Approved Provider Number</span><span style="font-family:'Arial Narrow', sans-serif">, Comcare claim number, Comcare service code, cost for each date of service.</span></p></td><td style="width:29.5pt; border-top:0.75pt dotted #000000; border-right:0.75pt dotted #000000; border-left:0.75pt dotted #000000; border-bottom:1pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border-top:0.75pt dotted #000000; border-right:0.75pt dotted #000000; border-left:0.75pt dotted #000000; border-bottom:1pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border-top:0.75pt dotted #000000; border-right:0.75pt dotted #000000; border-left:0.75pt dotted #000000; border-bottom:1pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border-top:0.75pt dotted #000000; border-right:0.75pt dotted #000000; border-left:0.75pt dotted #000000; border-bottom:1pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border-top:0.75pt dotted #000000; border-right:0.75pt dotted #000000; border-left:0.75pt dotted #000000; border-bottom:1pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td></tr><tr><td colspan="6" style="width:469.65pt; border-top:1pt solid #000000; border-right:0.75pt dotted #000000; border-bottom:1pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top; background-color:#cccccc"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif; font-weight:bold">Service Standard 6 – Evidence of </span><span style="font-family:'Arial Narrow', sans-serif; font-weight:bold">c</span><span style="font-family:'Arial Narrow', sans-serif; font-weight:bold">ompliance with </span><span style="font-family:'Arial Narrow', sans-serif; font-weight:bold">o</span><span style="font-family:'Arial Narrow', sans-serif; font-weight:bold">perational </span><span style="font-family:'Arial Narrow', sans-serif; font-weight:bold">s</span><span style="font-family:'Arial Narrow', sans-serif; font-weight:bold">tandards</span><span style="font-family:'Arial Narrow', sans-serif"></span></p></td></tr><tr><td style="width:267.95pt; border-top:1pt solid #000000; border-right:0.75pt dotted #000000; border-bottom:1pt solid #000000; padding-right:5.03pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif; font-weight:bold">6.1</span><span style="font-family:'Arial Narrow', sans-serif"> </span><span style="font-family:'Arial Narrow', sans-serif">Documentation is on file demonstrating ongoing compliance with these standards.</span></p></td><td style="width:29.5pt; border-top:1pt solid #000000; border-right:0.75pt dotted #000000; border-left:0.75pt dotted #000000; border-bottom:1pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border-top:1pt solid #000000; border-right:0.75pt dotted #000000; border-left:0.75pt dotted #000000; border-bottom:1pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border-top:1pt solid #000000; border-right:0.75pt dotted #000000; border-left:0.75pt dotted #000000; border-bottom:1pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border-top:1pt solid #000000; border-right:0.75pt dotted #000000; border-left:0.75pt dotted #000000; border-bottom:1pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td><td style="width:29.55pt; border-top:1pt solid #000000; border-right:0.75pt dotted #000000; border-left:0.75pt dotted #000000; border-bottom:1pt solid #000000; padding-right:5.03pt; padding-left:5.03pt; vertical-align:top"><p style="margin-top:5pt; margin-bottom:5pt; font-size:10pt"><span style="font-family:'Arial Narrow', sans-serif"></span></p></td></tr></tbody></table>

Section 2 – Agreement and authorisation

I, _________________________________________________________________

(please print full name)

holding the position of: ______________________________________________ ,

(please print title)

on behalf of the provider: _____________________________________________

(please print name of provider)

1. certify that the information provided in this renewal application and in support of the renewal application is true and correct. I understand that giving false or misleading information is a serious offence under the Criminal Code

2. agree to advise Comcare as soon as possible of any changes to the information provided in this renewal application

3. authorise relevant persons to provide to Comcare personal information in relation to this renewal application and for the purposes of enabling Comcare to determine whether the provider, a relevant principal or employee of the provider is complying with the Operational Standards For Rehabilitation Program Providers determined under section 34E of the SRC Act. In particular, I understand that this authorises Comcare to seek confirmation of the qualifications, probity and financial standing of the provider, relevant principals and the provider’s employees and the effectiveness, availability and cost of the rehabilitation programs which were provided by the provider, and

If the provider’s approval as a rehabilitation program provider is renewed,

4. understand that failure to comply with the Operational Standards for Rehabilitation Program Providers determined under section 34E of the SRC Act or the Criteria for Approval or Renewal of Approval of Rehabilitation Program Providers determined under section 34D of the SRC Act may result in the revocation of approval under section 34Q of that Act

5. agree to advise Comcare in writing within one month of any changes in individuals employed or engaged by the provider to manage return to work plans under the SRC Act, including evidence of qualifications and experience, and

6. agree to Comcare listing details about the provider on Comcare’s website.

Signed ………………………………………… (Applicant)

Date …………………………………………

What does Comcare mean by “certified copy”?

Applicants for approval or renewal of approval as rehabilitation providers by Comcare are required to submit documentary evidence in support if their application.

In the case of some of this evidence Comcare requires either an original document (returnable) or a certified copy of that document to be submitted.

Certified copies (or originals) are required of the following classes of document:

• All certificates held by applicants or their employees which are evidence that the applicant/employee possesses a degree or graduate diploma as described in Criterion 1.2 (a)
• All documentation submitted as evidence that the applicant/employee is currently registered with a relevant registration authority as described in Criterion 1.2 (c)
• All documentation submitted as evidence that the applicant/employee is a full member of a professional association related to the qualification referred to in the previous paragraph, or that they are eligible to be a full member of that association as described in Criterion 1.2 (d)
• All documentation relating to insurance coverage as described in Criterion 3.1(b) (see note below).

The certification consists of an endorsement on the actual copy which states that an appropriate person has sighted the original document and believes the copy to be a true copy of that document. A list of appropriate persons is at page two of this document. The person making the endorsing statement must sign the actual copy being provided to Comcare. This signature cannot be photocopied. For clarity that the signature is original, Comcare would prefer that it be in blue ink.

Send all requests for information to:

Approved Rehabilitation Providers – approval and renewal
Comcare
PO Box 9905
Canberra ACT 2601

Persons who can certify a document to Comcare

1. Agent of the Australian Postal Corporation who is in charge of an office supplying postal services to the public

2. Australian Consular Officer or Australian Diplomatic Officer within the meaning of the Consular Fees Act 1985

3. Bailiff

4. Bank, building society, credit union or finance company officer with 5 or more continuous years of service

5. Chiropractor

6. Civil marriage celebrant

7. Commissioner for Affidavits or for Declarations

8. Dentist

9. Fellow of the National Tax Accountants’ Association

10. Judge, magistrate, master, clerk, registrar or deputy registrar of a court, or chief executive officer of a Commonwealth court

11. Legal practitioner

12. Medical practitioner

13. Member of the Association of Taxation and Management Accountants, the Institute of Chartered Accountants in Australia, the Australian Society of Certified Practising Accountants or the National Institute of Accountants

14. Member of the Australian Defence Force who is:

a) an officer, or

b) a non-commissioned officer within the meaning of the Defence Force Discipline Act 1982 with five or more years of continuous service, or

c) warrant officer within the meaning of that Act.

15. Member of the Institute of Corporate Managers, Secretaries and Administrators

16. Member of the Engineers Australia, other than at the grade of student

17. Member of a Commonwealth, State or Territory parliament, legislature or local government authority

18. Minister of religion registered under Division 1 of Part IV of the Marriage Act 1961

19. Notary Public

20. Nurse

21. Patent attorney

22. Permanent employee of a Commonwealth, State, Territory or local government authority with five or more years of continuous service

23. Permanent employee of the Australian Postal Corporation with five or more years of continuous service who is employed in an office supplying postal services to the public

24. Person before whom a statutory declaration may be made under the law of the State or Territory in which the declaration is made

25. Pharmacist

26. Physiotherapist

27. Police officer

28. Psychologist

29. Senior Executive Service officer of the Commonwealth, or of a State or Territory, or of a Commonwealth, State or Territory authority

30. Sheriff or Sheriff’s officer

31. Teacher employed on a full time basis at a school or tertiary education institution

32. Veterinary surgeon

33. Justice of the Peace