SCHEDULE 1 - Form for Purpose SCHEDULE 1 - Form for Purpose of Section 33A of Act

Regulation 19

| | FORM FOR INFORMATION AS TO RIGHT TO MAKE WORKER'S COMPENSATION CLAIM | | | Form for information under section 33A of the Workers Rehabilitation and Compensation Act 1988 | | 1. | On [insert date on which notice of injury was given by worker*] you notified the employer named below (“your employer”) that you had suffered an injury that you believe was caused by your employment with your employer. | | 2. | In accordance with section 33A of the Workers Rehabilitation and Compensation Act 1988, I advise, on behalf of your employer, that you have the right under that Act to make a claim for compensation for the injury. | | 3. | If you wish to make a claim for compensation, you should do so as soon as practicable. | | 4. | Generally, you may only make the claim within 6 months after the date on which the injury occurred. However, if the injury consists of a loss of hearing due to exposure to industrial noise, you may only make the claim while you are still employed by your employer or within 6 months after you stop being employed by your employer. | | 5. | A claim for compensation must be made on the approved form. You may ask your employer for a copy of the approved form. | | 6. | You must attach to a claim for compensation a worker’s compensation medical certificate that has been issued by a medical practitioner. | | 7. | You must tell your employer the name of the medical practitioner who is to have primary responsibility for treating your injury. The practitioner is to provide medical certificates, coordinate your medical treatment for the injury and, if necessary, assist in your rehabilitation and return to work. | | 8. | If you wish to talk with your employer about any matter related to this notice, you may speak to [insert name of person nominated by employer*] who may be contacted on [insert contact telephone number*]. | | 9. | If you need assistance in relation to the injury or a claim for compensation, you may telephone the WorkSafe Tasmania Helpline on 1300 366 322 or, for callers outside Tasmania, 03 6166 4600. | | | Signed by………………[Signature*] | | | On behalf of the following employer:……………………………..[Name of employer*] | | | Note: Items marked with an asterisk are to be completed by a person authorised by the employer to give this notice to the injured worker. |