Store Return to Work -Rehabilitation and Return to Work site visit SRTWS Tracey Goodman

• Document No.

• Store Rehabilitation and Return to Work site visit

Store Rehabilitation and Return to Work site visit

• WOOLWORTHS

• Conducted on

  Date

• Prepared by Tracey Goodman

• Location
  Address

• Personnel

Employee details

• Employee name

• Claim number

• Date of injury

• Injury Details

Medical information

• Is there a current medical certificate

  Yes

  No

  N/A

• Is there any restrictions noted on the medical certificate

  Yes

  No

  N/A

• Is there any reduction in hours

  Yes

  No

  N/A

• Is there another doctor review

  Yes

  No

  N/A

• Does the RTWC/Store Manager attend Doctors review to discuss Return to Work/Suitable duties

  Yes

  No

  N/A

• Is there current treatment (eg physio)

  Yes

  No

  N/A

• Is there any surgery planned (include date)

  Yes

  No

  N/A

Return to work

• Is there a Return to Work plan in Place

  Yes

  No

  N/A

• Is the Return to work plan current (include date for review)

  Yes

  No

  N/A

• Is there store assistance with an external rehabilitation provider

  Yes

  No

  N/A

• If there is not a Return to work plan Is there a current work schedule developed instore with suitable duties

  Yes

  No

  N/A

• Is there a Graduated return to work plan for a planned increase in capacity

  Yes

  No

  N/A

• Are the duties suitable and safe to perform within restrictions

  Yes

  No

  N/A

• Is there any barriers to upgrades

  Yes

  No

  N/A

• RTW Goal

Return to work activities

• Is the injured worker coping with the current hours and duties

  Yes

  No

  N/A

• Are duties being provided within capacity

  Yes

  No

  N/A

• Is their line manager supporting the program

  Yes

  No

  N/A

• Is the injured worker working within the restrictions

  Yes

  No

  N/A

• Is there anything more the injured worker feels the store can do to assist their recover

  Yes

  No

  N/A

• Can the store assist (include detail)

  Yes

  No

  N/A

• Is the injured worker coping with home activites

  Yes

  No

  N/A

Action Items

• Is there any actions to be completed

  Yes

  No

  N/A

• Additional comments.