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Employee
Assistance Program
Mediation
Safety
and Health
Injury
Management
Workers'
Compensation
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Below is a description of all the forms used throughout
the workers' compensation system and by the Department. Once an Employees
Report Form 2B and First Medical Certificate are submitted, they should
be date stamped and forwarded within three days to the Employee
Support Bureau, Education and Training Shared Services Centre, GPO Box
2622, PERTH, WA,6001.
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Form
1B - Employer's Report Form - this is to be completed
by the Principal or line manager. Please ensure that the 'Date of
Lodgement with Employer' section is completed. It appears approximately
half way down the page and may be in red. There is no requirement
for you to complete page two of this form. Back
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Form
2B - Employee's Report Form - this form is to be completed
by the injured employee. Please ensure that both the signature of
the injured worker and a person who witnesses the injured worker's
signature are placed in both places in the 'Injured worker's declaration'
section of the form. The Privacy Amendment Act section also needs
to be completed. Back to top |
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Form
3A - Recurrence of Disability Form - this is to be filled
out when an employee has had a previous claim for workers' compensation
and has had an aggravation of that injury. The claim may have been
closed or not actioned for greater than three months. If an injured
employee has then received further medical treatment for this injury,
they will need to complete this form and attach a relevant Workers'
Compensation Progress Medical Certificate from their doctor. Also,
if an injured worker has been certified fit and then becomes unfit
again, they will also need to complete this form. Back
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Form
4 - Travel Accident Form - this form is to be completed
if an employee is involved in a motor vehicle accident while undertaking
Departmental business. Journey's to and from your place of residence
are not covered by workers' compensation. Back
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Form
5A - Witness Statement Form - this is to be completed
by an eye witness to the accident/injury or a person having knowledge
of the accident/injury. You can attach more than one witness statement
form. In the event of there being no witnesses to the injury, a
detailed statement from the injured worker would be of assistance.
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Accident/Incident
Investigation Form
- this is to be completed by the nominated Safety and Health
Representative or principal/line manager to identify how the injury
occurred and why, in order to prevent a similar injury in the future.
This form is to be forwarded with the claim for workers' compensation.
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Reimbursement
of Travel Expenses - this form is available to claim
reasonable travel related expenses (e.g. travel to specialist appointments,
physio, doctors). The current rate for travel allowance is 29c/km.
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Workers'
Compensation First Medical Certificate - this is to be issued by
the initial treating doctor and forwarded with the injured workers'
claim forms. If this form is not present, a claim cannot be lodged.
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Workers'
Compensation Progress Medical Certificate - this is issued by your
doctor or specialist for ongoing visits or time off during your claim.
It is a requirement to keep your medical cover current. Back
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Workers'
Compensation Final Medical Certificate - this is issued by your
doctor when he/she thinks you have fully or partially recovered from
your injury. Back to top
All
forms are to be forwarded directly to the Department, in turn these
will be forwarded to RiskCover, the Department's insurers for further
processing and a determination on liability.
The Department,
as a guide for principals and line managers, have also developed the
following information sheets.
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- Detailed
Workers' Compensation Form Checklist.
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Occupational
Stress Claims
In addition to the
forms listed above, the Department's Injury Management Consultants, Claims
Officer or RiskCover may request a detailed statement from the injured
employee outlining the factual details that led up to the claim being
lodged.
Some suggested questions
for the injured worker to consider might be:
- Provide a brief
outline of your teaching/work background and employment at the school/office.
- Describe in detail
what events (chronological order, if possible) that contributed to your
injury/illness.
- Outline any support
that has been actioned by yourself, treating doctor and/or school/office
(i.e. referred to counselling).
- Provide an outline
of what is currently occurring (i.e. are you back at work).
An example of questions
the principal or line manager might be asked are:
- Provide a brief
outline of the employee's teaching/work background and their employment
at the school/office.
- Provide a factual
account of how the situation arose, attaching any correspondence or
copies of documents that are relevant.
- Outline the support
that was actioned (i.e. employee referred to counselling).
- Provide an account
of any preventative measures that were put in place prior to the incident
and post incident.
- Provide an outline
of what is currently occurring with the employee (i.e. are they back
at work or if the employee is not at work, have they been contacted
by someone at the school).
- Any other factors
that may have resulted in this employee lodging a workers' compensation
claim. Back to top
If you have any further
questions regarding any of the above forms, please contact the administrative
assistants in the workers' compensation section. Questions regarding
occupational stress should be directed to the
Injury Management
Consultant concerned.
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