Injured Worker Checklist

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

I. Injured Worker After Injury

• Worker received first aid or medical treatment

  Yes

  No

  N/A

• Notified worker's family or next of kin

  Yes

  No

  N/A

• Obtained written authority from the worker for release of information

  Yes

  No

  N/A

• Discussed RTW with the worker, doctor and/or insurer

  Yes

  No

  N/A

• Discussed preventive measures with the worker to avoid recurrence

  Yes

  No

  N/A

II. Injured Worker During Recovery

• Maintained regular contact with worker

  Yes

  No

  N/A

• Briefed worker on RTW process and the role of stakeholders

  Yes

  No

  N/A

• Assessed RTW barriers and developed strategies

  Yes

  No

  N/A

• Contacted insurer about RTW

  Yes

  No

  N/A

III. Return to Work Planning/Suitable Duties Program

• Identified RTW needs

  Yes

  No

  N/A

• Host employee discussed with insurer if no suitable duties are available at usual workplace

  Yes

  No

  N/A

• RTW time/date confirmed with injured worker, supervisor and others

  Yes

  No

  N/A

• Completed consultations and case conferences with stakeholders

  Yes

  No

  N/A

• Briefed co-worker about SDP and worker duties

  Yes

  No

  N/A

Completed SDP requirements

• Shows goals, objectives, timeframes, review date

• Consistent with medical certificate/report, worker's injury, experience, education and age

• Duties are meaningful and have regard to the objective of the worker's rehabilitation

• Copy provided to worker and supervisor

• Copy sent to the insurer

• Copy kept on worker's file

Completed required worker interactions

• Support needs identified

• Met at start of first day to explain RTW process

• Monitored for pain/distress on first day

• Asked for feedback after first day of RTW

IV. Improvement Planning

• Obtained feedback from the following

  Select Worker Supervisor Rehabilitation Professional

  • Worker
  • Supervisor
  • Rehabilitation Professional

• Worker still employed 12 months later?

  Yes

  No

  N/A

• Completed by:

  Sign