Title Page
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Name of Worker
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Date of Birth
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Worker Phone
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Worker Email
Emergency Contact Details
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Emergency Contact Name
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Emergency Contact Phone
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Is this worker a labour hire employee working at a Client site?
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Client Name
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Client Supervisor / Injury Management Contact
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Phone
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Email
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Insurer
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Claim Number
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Conducted on
Zenith Search Contact Details
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Plan Developed By
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Phone Number
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Email
Pre-Injury Work information
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Worker's Pre-Injury Job Title
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What was the typical work schedule before the injury?
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What tasks or duties were part of the job before the injury?
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Did the pre-injury work involve any specific equipment or machinery?
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Please describe
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Were there any physical demands (e.g., lifting, standing, repetitive movements) in the workers regular work before the injury?
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Please specify
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Did your pre-injury work include any travel or working at different sites?
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Please provide details
Return to Work Plan
Nature of the Injury/Illness
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Date of Injury
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Type of Injury/Illness
- Sprain/Strain
- Fracture/Break
- Laceration/Cut
- Contusion/Bruise
- Burn (Thermal/Chemical)
- Dislocation
- Repetitive Strain Injury (RSI)
- Concussion/Head Injury
- Hearing Loss
- Respiratory Condition
- Skin Condition (e.g., Dermatitis)
- Eye Injury
- Psychological Injury/Stress
- Other
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Please specify:
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Affected Body Part(s)
- Head/Neck
- Shoulder
- Arm/Elbow
- Wrist/Hand/Fingers
- Back (Upper/Lower)
- Hip
- Leg/Knee
- Ankle/Foot/Toes
- Chest/Abdomen
- Internal Organs
- Respiratory System
- Eyes
- Skin
- Other
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Please specify:
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Cause of Injury/Illness
- Slip/Trip/Fall
- Lifting/Manual Handling
- Struck by Object
- Contact with Machinery/Equipment
- Exposure to Harmful Substances
- Repetitive Motion
- Vehicle Accident
- Workplace Violence/Assault
- Stress/Workload
- Other
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Please specify:
Medical Restrictions and Capacity
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Are there any medical restrictions or limitations provided by the treating health practitioner, such as weight-lifting limits, standing/sitting duration, or avoiding specific movements?
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Please summarize any restrictions or limitations provided by the treating health practitioner, such as weight-lifting limits, standing/sitting duration, or avoiding specific movements, or take a photo of the medical certificate by clicking media.
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What changes to the worker’s duties and hours are required (including what tasks will be suitable, what tasks they should avoid, and when they will be required)?
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Is the client willing to support in with these suitable duties?
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What alternatives are in place to help support return to work (e.g. another client similar role, helping at the Zenith Search office)?
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Is there any reduction in the worker's capacity to perform their usual duties, including any limitations in physical or cognitive abilities?
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Please provide details from the Certificate of Capacity, such as the worker’s current capacity for work, including any hours or duties they are able to perform, or take a photo of the medical certificate by clicking media.
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Are there any changes to the work environment, processes or practices to support the worker’s recovery and return to work?
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What are they and when will they be required?
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Is there any upcoming treatment that may impact return to work arrangements or that need to be considered?
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What is the treatment, when is the treatment and how long is it?
Discussions with Treating Health Practitioner/Worker
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Were you present for the medical appointment?
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Please summarize key points from conversations with the treating health practitioner and/or the worker about their ability to return to work.
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Were there any expected recovery timelines discussed?
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Please specify
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Have any concerns been raised by the worker in relation to return to work?
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What are the concerns?
Finalization
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Worker - I will actively participate in this plan.
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Zenith Search Consultant - I will implement this plan and support the worker through their return to work.
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Client Supervisor - I will implement this plan and support the worker through their return to work.
