Western Australia Workers' Compensation and Injury Management Act 1981 Workers' Compensation and Injury Management Regulations 1982 Western Australia Workers' Compensation and Injury Management Regulations 1982 CONTENTS Part 1 - Preliminary 1. Citation 1 2. Commencement 1 Part 2 - General 2A. Indexation of child's allowance and redemption amount 2 3. Certain registered bodies specified for the definition of company in Act 2 4A. Certain mines, mining operations prescribed for the definition of mine or mining operation in Act 3 4. Form of election 3 5. Determination form for medical panel 4 6AA. Form of claim for compensation 4 6AB. Relevant document (section 180(1)(j)) 4 6A. Form of medical certificate 4 6B. Form for insurer accepting liability 5 6C. Form for insurer disputing liability 5 6D. Form for insurer undecided on liability 5 6E. Form for employer disputing liability 5 6F. Form for employer undecided on liability 5 7. Discontinuance or reduction of weekly payments 6 8. Frequency and time of medical examinations (section 66) 6 9. Compound discount table 7 9A. Discount formula 7 10. Worker not residing in the State 8 11. Payments after death outside the State 9 12. Agreements 10 12AA. Notice of intention to dismiss worker (section 84AB) 12 12A. Contributions to General Account 12 13. Ascertaining amount for reimbursement (section 154AC(1)) 12 13A. Prescribed rate of interest (sections 222(2), 223(2) and 224(2)) 13 15. Statements by approved insurance offices 14 16A. Clause 1C notifications and elections 14 17. Prescribed allowance (clause 11(2)) 15 17AA. Prescribed rate for vehicle running expenses (clause 19(1)) 16 17AB. Exceptional circumstances (clause 18A(2aa)(c)(ii)) 16 17AC. Management plan (clause 18A(2ac)) 17 17AD. Extending final day 18 17AE. Amount prescribed for funeral expenses (clause 17(2)) 18 17A. Supplementary amount 19 17B. Witness allowances 20 18. Form of election to receive redemption amount or supplementary amount 20 Part 2A - Assessment of costs 18A. Application of this Part 22 18B. Terms used 22 18C. Application for assessment of costs 23 18D. Taxing officer may require application to be given to other persons 23 18E. Taxing officer may require documents or further particulars 24 18F. Consideration of application 24 18G. Assessment to give effect to order and costs determination 25 18H. Matters to be considered 25 18I. Cost of assessment 26 18J. Enforcement of assessment 26 18K. Correction of error 26 18LA. Transitional provision 27 Part 2B - Medical assessment 18L. Terms used 28 18M. Request for assessment by approved medical specialist of worker's degree of impairment 29 18N. Requirement to attend at place specified by approved medical specialist 29 18O. Requirement to produce to approved medical specialist relevant documents and information and give consent 30 18P. Period for compliance with requirements 31 18Q. Requirement for worker to produce requested information 31 18R. Reports and certificates regarding outcome of assessment 32 18S. Requirement to attend at place specified by approved medical specialist panel 33 18T. Requirement to produce to approved medical specialist panel relevant documents and information and give consent 33 18U. Period for compliance with requirements 34 18V. Requirement for worker to produce requested information 34 18W. Reports and certificates regarding outcome of assessment 35 Part 3 - Noise induced hearing loss 19A. Terms used 36 19B. Persons approved to carry out audiometric testing 36 19C. Testing procedures 37 19D. Notice of audiometric test and testing arrangements 41 19E. Calculation of loss of hearing 41 19F. Report on audiometric test and storage of results 41 19H. Retest of person's hearing 42 19I. Prescribed workplaces 43 Part 3A - Constraints on awards of common law damages Division 1 - 1993 scheme 19IA. Guides for assessing degree of disability 45 19J. Assessment of degree of disability 45 19JA. Method of referral and notification when section 93EA(3) of the Act applies 46 19JB. Method of referral and notification when section 93EB(3) of the Act applies 47 19K. Agreement as to degree of disability 48 19L. Determination of degree of disability 48 19M. Election to retain right to seek common law damages 49 19N. Extension of time to make election under section 93E(3)(b) 50 19O. Application for compensation 53 19P. Notification to workers about elections as to common law damages 53 Division 2 - 2004 scheme 20. Recording agreement 54 21. Recording assessment 55 22. Electing to retain right to seek damages 56 23. Extending termination day 57 24. Expected time for approved medical specialist to give assessment documents 59 25. Employer's obligation to notify worker 59 Part 4 - Registered agents Division 1 - Preliminary 26. Terms used 60 27. Prescribed organisations (section 277(1)(e)) 61 27A. Prescribed classes of persons (section 277(1)(f)) 61 Division 2 - Registration and renewal 28. Application for registration 61 29. Registration 63 30. Indemnity and other conditions of registration 64 31. Duration of registration 65 32. Application for renewal of registration 66 33. Certificate of registration 66 34. False or misleading information 67 Division 3 - The register 35. Register 67 36. Removal from register 68 Division 4 - Disciplinary powers 37. Restriction on exercise of powers 68 38. Cancellation of registration 69 39. Taking disciplinary action 69 40. Return of certificate of registration 69 Division 5 - Review 41. Review 70 Division 6 - Miscellaneous 42. Evidentiary matters 70 Part 5 - Injury management 44. Vocational rehabilitation services 72 44A. Counselling psychology 75 44B. Exercise physiology 75 45. Insurer to advise of injury management obligations 76 Part 6 - Specialised retraining programs 47. Recording agreement 77 48. Extending final day 78 49. Request for WorkCover to direct payment 79 Part 7 - Infringement notices and modified penalties 50. Prescribed offences 80 51. Prescribed modified penalties 80 52. Prescribed form of infringement notice 80 53. Prescribed form of withdrawal of notice 80 Appendix I Appendix II Appendix III Appendix IV - Registered agents code of conduct 1. Duties of registered agent 205 2. Integrity and diligence 205 3. Confidentiality 206 4. Conflict of interest 206 5. Proceedings 207 6. Advertising 208 7. Withdrawal 208 8. Fees 209 9. Records 210 10. Trust moneys 210 11. Costs 210 Appendix V - Prescribed offences and modified penalties Notes Compilation table 214 Defined Terms Western Australia Workers' Compensation and Injury Management Act 1981 Workers' Compensation and Injury Management Regulations 1982 Part 1 - Preliminary [Heading inserted in Gazette 26 Feb 1991 p. 933.] 1. Citation These regulations may be cited as the Workers' Compensation and Injury Management Regulations 1982 1. [Regulation 1 amended in Gazette 8 Mar 1991 p. 1071; 21 Jan 2005 p. 275.] 2. Commencement These regulations shall come into operation on the date of the coming into operation of the Workers' Compensation and Injury Management Act 1981 1, 2. Part 2 - General [Heading inserted in Gazette 26 Feb 1991 p. 933.] 2A. Indexation of child's allowance and redemption amount (1) If the minimum award rates that would be relevant to calculating the amount of - (a) the child's allowance, as defined in section 5(1) of the Act; or (b) the redemption amount, as defined in the Act Schedule 5 clause 1, for a particular financial year are not published, the amount to be calculated for that financial year (the relevant year) is to be obtained by varying the amount for the preceding financial year as described in subregulation (2). (2) To vary an amount as described in this subregulation, it is varied by the percentage by which the amount that the Australian Statistician published as the Labour Price Index (formerly known as the Wage Cost Index), ordinary time hourly rates of pay (excluding bonuses) for Western Australia varied between the second-last December quarter before the relevant year commenced and the last December quarter before the relevant year commenced. [Regulation 2A inserted in Gazette 17 Nov 2000 p. 6309-10; amended in Gazette 28 Oct 2005 p. 4861; 19 Mar 2010 p. 1038.] 3. Certain registered bodies specified for the definition of company in Act (1) For the purposes of the definition of company in section 5(1) of the Act, the following registered bodies are specified - (a) a registered Australian body that was formed or incorporated in the State; (b) a registered Australian body that was not formed or incorporated in the State and that does not have its head office or principal place of business in the State. (2) In this regulation - registered Australian body has the meaning given by the Corporations Act 2001 of the Commonwealth. [Regulation 3 inserted in Gazette 28 Sep 2001 p. 5357.] 4A. Certain mines, mining operations prescribed for the definition of mine or mining operation in Act (1) The classes of mine that are prescribed for the purposes of the definition of mine or mining operation in section 5(1) of the Act are those mines that are a mine as defined in the Mines Safety and Inspection Act 1994 section 4(1). (2) The classes of mining operation that are prescribed for the purposes of the definition of mine or mining operation in section 5(1) of the Act are those mining operations that are mining operations as defined in the Mines Safety and Inspection Act 1994 section 4(1). [Regulation 4A inserted in Gazette 19 Mar 2010 p. 1038-9.] 4. Form of election (1) The form of election referred to in section 24B of the Act shall be in Form 1 or, in the case of a worker suffering from noise induced hearing loss, Form 2C in Appendix I. (2) The form of election referred to in section 31H of the Act must be in the form of Form 1A in Appendix I or, in the case of a worker suffering from noise induced hearing loss, in the form of Form 2CA in Appendix I. [Regulation 4 amended in Gazette 26 Feb 1991 p. 934; 25 Aug 1995 p. 3885; 28 Oct 2005 p. 4862.] 5. Determination form for medical panel Pursuant to section 38(2) of the Act, the form of the determination of the medical panel shall, as far as practicable in each case, be as set out in Form 2 in Appendix I. [6. Deleted in Gazette 15 Oct 1999 p. 4900.] 6AA. Form of claim for compensation (1) Form 2B or, in the case of a worker suffering from noise induced hearing loss, Form 2C or Form 2CA, as the case requires, in Appendix I is prescribed for the purposes of a claim made by a worker in accordance with section 178(1)(b) of the Act. [(2) deleted] (3) Form 2D in Appendix I is prescribed for the purposes of a claim for compensation made by dependants in the case of the death of a worker in accordance with section 178(1)(b) of the Act. [Regulation 6AA inserted in Gazette 28 Jun 1991 p. 3291; amended in Gazette 18 Feb 1994 p. 660; 25 Aug 1995 p. 3885; 13 Apr 1999 p. 1531- 2; 15 Oct 1999 p. 4900; 28 Oct 2005 p. 4862; 10 Sep 2010 p. 4352.] 6AB. Relevant document (section 180(1)(j)) A certificate of currency in respect of the employer's insurance policy referred to in section 160(7) of the Act is prescribed under section 180(1)(j) of the Act as a relevant document. [Regulation 6AB inserted in Gazette 28 Oct 2005 p. 4863.] 6A. Form of medical certificate (1) Form 3 in Appendix I is the prescribed form under sections 57A(1)(b)(i) and 57B(1)(b)(i) of the Act. (2) In addition to the details prescribed in Form 3 as being necessary to make a valid claim for compensation under sections 57A and 57B, the "Consent authority" is prescribed under section 292(1)(a) as expedient for the purposes of the Act, and is to be completed accordingly. [Regulation 6A inserted in Gazette 8 Mar 1991 p. 1071; amended in Gazette 13 Apr 1999 p. 1532; 28 Oct 2005 p. 4863; 18 Nov 2011 p. 4820.] 6B. Form for insurer accepting liability Form 3A in Appendix I is the prescribed form under section 57A(3)(a) of the Act. [Regulation 6B inserted in Gazette 8 Mar 1991 p. 1071.] 6C. Form for insurer disputing liability Form 3B in Appendix I is the prescribed form under section 57A(3)(b) of the Act. [Regulation 6C inserted in Gazette 8 Mar 1991 p. 1071.] 6D. Form for insurer undecided on liability Form 3C in Appendix I is the prescribed form under section 57A(3)(c) of the Act. [Regulation 6D inserted in Gazette 8 Mar 1991 p. 1071.] 6E. Form for employer disputing liability Form 3D in Appendix I is the prescribed form under section 57B(2)(b) of the Act. [Regulation 6E inserted in Gazette 8 Mar 1991 p. 1071.] 6F. Form for employer undecided on liability Form 3E in Appendix I is the prescribed form under section 57B(2)(c) of the Act. [Regulation 6F inserted in Gazette 8 Mar 1991 p. 1071.] 7. Discontinuance or reduction of weekly payments (1) The medical certificate required by section 61 of the Act, before discontinuance of weekly payments, shall be in the form of Form 4 in Appendix I, or in the form of Form 3 in Appendix I if that form has been marked to indicate that it is to be regarded as both a first and final medical certificate. (2) Notice to the worker referred to in section 61 of the Act shall be in the form of Form 5 in Appendix I. (3) The period commencing on the making of an application for conciliation of a dispute about the intention of an employer to discontinue or reduce weekly payments to a worker and ending when a certificate under section 182H or 182O is issued in respect of the dispute is to be disregarded for the following purposes - (a) calculating the period of notice of the intention of the employer under section 61(1); (b) calculating the time within which the worker may apply for an order of an arbitrator under section 61(3). [Regulation 7 amended in Gazette 29 Oct 1993 p. 5930; 13 Apr 1999 p. 1532; 18 Nov 2011 p. 4820.] 8. Frequency and time of medical examinations (section 66) (1) A worker who receives a First Medical Certificate (Form 3) under the Act which nominates a medical review of the worker within a period of 14 days from the date the certificate is issued cannot be required, under section 64 or 65 of the Act, to submit himself for examination by a medical practitioner provided by the employer before a period of one month has elapsed from the date the certificate is issued. (2) A worker who receives a First Medical Certificate (Form 3) under the Act which does not nominate a medical review of the worker within a period of 14 days from the date the certificate is issued may be required, under section 64 or 65 of the Act, to submit himself for examination by a medical practitioner provided by the employer at any time from the date the certificate is issued. (3) A worker who fails to attend a medical review, nominated on a First Medical Certificate in accordance with subregulation (1), may be required, under section 64 or 65 of the Act, to submit himself for examination by a medical practitioner provided by the employer at any time from the date of that non-attendance. (4) An employer shall not require a worker to attend an examination under section 64 or 65 of the Act - (a) more frequently than once every 2 weeks; or (b) at any time other than during reasonable hours. (5) A worker must not, under section 64 or 65 of the Act, be required to attend medical examinations by more than 3 medical practitioners who are specialists in the same field of medicine. (6) Nothing in subregulation (5) limits the number of times a worker may be required to attend a medical examination by a medical practitioner. [Regulation 8 inserted in Gazette 13 Apr 1999 p. 1532-3; amended in Gazette 28 Oct 2005 p. 4863-4.] [8A. Deleted in Gazette 15 Oct 1999 p. 4890.] 9. Compound discount table The compound discount table required to be prescribed by section 68(3) of the Act is set out in Appendix II. [Regulation 9 amended in Gazette 2 Sep 1988 p. 3464; 15 Oct 1999 p. 4890.] 9A. Discount formula When calculating a lump sum redemption under section 68 of the Act the following formula shall be applied for use in conjunction with a compound discount table as set out in Appendix II. DISCOUNT FORMULA UNDER SECTION 68(4) |Discounted sum = P x 52 x A | |Where - | |S = prescribed amount less the sum of | |weekly payments made | |P = the weekly payment | |[pic] | |Y = the whole number equal to or next | |below [pic] | |W = T - (52 x Y) | |A = the present value of $1.00 per annum | |payable weekly for Y years and W weeks | |obtained from the compound discount tables| |set out in Appendix II. | [Regulation 9A inserted in Gazette 25 Jul 1986 p. 2484; amended in Gazette 2 Sep 1988 p. 3464.] 10. Worker not residing in the State (1) For the purposes of section 69 of the Act, a worker shall prove his identity and the continuance of the incapacity in respect of which a weekly payment is payable, by delivering to the employer or the employer's insurer, at intervals of 3 months, a declaration by the worker and by a medical practitioner in the form of or to the effect of Form 6 in Appendix I. (2) Where an employer, or an employer's insurer, disputes the identity or entitlement, or both, of a worker, the employer or insurer - (a) may apply under section 182E of the Act for resolution of the dispute by conciliation; and (b) if the dispute is not resolved by conciliation, may apply under section 182ZT for determination of the dispute by arbitration. [Regulation 10 amended in Gazette 2 Sep 1988 p. 3464; 24 Dec 1993 p. 6844; 18 Feb 1994 p. 661; 17 Nov 2000 p. 6310; 28 Oct 2005 p. 4864; 18 Nov 2011 p. 4820-1.] [10A. Deleted in Gazette 18 Nov 2011 p. 4821.] [10B. Deleted in Gazette 28 Oct 2005 p. 4864.] 11. Payments after death outside the State (1) In the event of the death of a worker who dies outside the State and who was receiving or was entitled to receive weekly payments at the date of his death, his representatives shall, for the purpose of obtaining payment of the arrears (if any) due to the worker, forward to the Director a certificate of the death of the worker, and documents showing that they are entitled to such arrears, verified by declaration before a person having authority to administer an oath, with a request for payment of such arrears, specifying the place where and the manner in which the amount is to be remitted to them. (2) For the purposes of this regulation the expression representatives means - (a) if the worker leaves a will, the executors of the will; or (b) where the worker dies intestate, the persons who are according to law entitled to his personal estate, and payment of the arrears may be made to the persons without the production of letters of administration. (3) On receipt of the certificate of death and the documents mentioned in this regulation, the Director shall examine them, and may, if not satisfied that they are in order, return them to the representatives for correction. (4) When the Director is satisfied that the certificate and documents are in order, or when they are returned to him in order, he shall send to the employer a notice requesting him to forward the amount due, and the employer shall thereupon forward the amount to the Director, who shall remit that amount, to the representatives of the worker at the address and in the manner requested by them, such remittance being in all cases at the risk of the representatives. [Regulation 11 amended in Gazette 18 Feb 1994 p. 661.] 12. Agreements (1) A memorandum of an agreement referred to in section 76 of the Act is sent to the Director in accordance with that section by sending it to the Director as soon as practicable after the agreement has been entered into, with enough copies for the memorandum to be kept in the office of WorkCover WA and a copy to be given to each interested party. (1a) A memorandum of an agreement referred to in section 76 of the Act shall be in the form of Form 15C in Appendix I. (2) The memorandum is to include full particulars of matters for which the agreement provides and, in the case of an agreement as to the compensation that is to be paid under Schedule 2 of the Act, is to identify each item for which the compensation is to be paid and, for each item - (a) if the Act Part III Division 2 applies in respect of the personal injury or noise induced hearing loss that is the subject of the agreement - (i) the percentage loss of the full efficient use of a part or faculty of the body for which compensation is to be paid; and (ii) the amount of compensation; or (b) if the Act Part III Division 2A applies in respect of the personal injury or noise induced hearing loss that is the subject of the agreement - (i) the degree of permanent impairment of a part or faculty of the body for which compensation is to be paid; and (ii) the amount of compensation. (3) The memorandum is to be signed by or on behalf of each party to the agreement and if the memorandum sent to the Director is not the original signed memorandum the original is to be produced for inspection by the Director. (3a) A memorandum of an agreement lodged for the purposes of a redemption amount under section 67(l) shall be accompanied by Form 15D in Appendix I signed and dated by the worker, as acknowledgment that he/she is aware of the consequences of the recording of the memorandum. (4) The notice despatched by the Director to each interested party, under section 76(2) of the Act, is to be in the form of Form 15A in Appendix I. (4a) Where any interested party disputes the genuineness of the memorandum, or the adequacy of the compensation agreed upon or otherwise objects to the recording of the agreement that party shall, within the 7 days allowed in section 76(2), notify the Director by completing Form 15E in Appendix I, and forwarding that completed form to the Director. (4b) On receipt of an objection from any party in the manner prescribed in subregulation (4a), the Director shall send to each other party a notice, in the form of Form 15F, informing such parties that the memorandum will not be recorded except with the consent in writing of the objector. (5) If the Director records the memorandum, the Director is to notify each interested party accordingly in the form of Form 15B in Appendix I. (6) The Director may vary or amend a memorandum if all parties first give the Director written consent to make that variation or amendment. (7) For the purpose of providing a statement of benefits paid, under section 67(2) of the Act, Part 4 of the Memorandum of Agreement form (Form 15C), may be used for this purpose. [Regulation 12 inserted in Gazette 18 Feb 1994 p. 661; amended in Gazette 15 Oct 1999 p. 4906-7; 28 Oct 2005 p. 4864-5; 18 Nov 2011 p. 4821.] 12AA. Notice of intention to dismiss worker (section 84AB) (1) This regulation applies to a notice of intention to dismiss a worker to which section 84AB of the Act refers. (2) Form 15G in Appendix I is the form prescribed for the notice. [Regulation 12AA inserted in Gazette 28 Oct 2005 p. 4865.] [12AB. Deleted in Gazette 28 Oct 2005 p. 4865.] 12A. Contributions to General Account (1) The amount prescribed for the purposes of section 109(1) of the Act is $100 000. (2) The amount prescribed for the purposes of section 109(4) of the Act is $40 000. [Regulation 12A inserted in Gazette 22 May 1987 p. 2193; amended in Gazette 2 Sep 1988 p. 3464; 22 Sep 1989 p. 3490-1; 6 Dec 1991 p. 6119; 16 Sep 2003 p. 4103; 28 Oct 2005 p. 4866.] 13. Ascertaining amount for reimbursement (section 154AC(1)) (1) WorkCover WA may approve an application by an employer for reimbursement under section 154AC(1) of the Act. (2) The amount that WorkCover WA is to reimburse to an approved applicant under section 154AC(1) of the Act is to be calculated by subtracting the estimated total cost from the actual total cost. (3) In this regulation - actual total cost, in relation to an award of damages, means the total amount paid on a claim (including all compensation paid in accordance with the Act, any award of damages, legal expenses and miscellaneous expenses associated with the claim, to the extent that these apply) by the insurer or self-insurer, as calculated in accordance with the Insurer/Self-Insurer Electronic Data Specification (Edition Q1), following an award of damages, as submitted to, and approved and recorded by, WorkCover WA; estimated total cost, in relation to an award of damages, means the insurer, or self-insurer's, estimate of the total cost of the claim (including the estimated compensation to be paid in accordance with the Act, any award of damages, legal expenses and miscellaneous expenses associated with the claim to the extent that these apply or are likely to apply), estimated in accordance with the Insurer/Self- Insurer Electronic Data Specification (Edition Q1), as at the date of creation of the May 2004 return file recorded by WorkCover WA; Insurer/Self-Insurer Electronic Data Specification (Edition Q1) means Edition Q1, Version 1.4.6 of the Insurer/Self-Insurer Electronic Data Specification, published by WorkCover WA on 29 July 2003 to standardise the information or return requested under section 103A of the Act. [Regulation 13 inserted in Gazette 26 Oct 2004 p. 4898-9; amended in Gazette 21 Jan 2005 p. 276.] 13A. Prescribed rate of interest (sections 222(2), 223(2) and 224(2)) (1) Interest payable under an order made under section 222(1) of the Act must be calculated at a rate of 6% per annum. (2) Interest payable under section 223(1) of the Act must be calculated at a rate of 6% per annum. (3) Interest payable under section 224(1) of the Act in respect of a sum agreed to be paid must be calculated at a rate of 6% per annum. [Regulation 13A inserted in Gazette 28 Oct 2005 p. 4866.] [14. Deleted in Gazette 28 Oct 2005 p. 4866.] 15. Statements by approved insurance offices The statements required to be transmitted to WorkCover WA under section 171 of the Act shall be in the form of Forms 16 and 17 in Appendix 1. [Regulation 15 inserted in Gazette 8 Mar 2002 p. 949; amended in Gazette 16 Sep 2003 p. 4104; 21 Jan 2005 p. 276.] [16. Deleted in Gazette 28 Oct 2005 p. 4866.] 16A. Clause 1C notifications and elections (1) The form of notification for the purposes of the Act Schedule 1 clause 1C(1) must be in the form of Form 29 in Appendix I. (2) The form of notification for the purposes of the Act Schedule 1 clause 1C(4)(a) must be in the form of Form 30 in Appendix I. (3) An election for the purposes of the Act Schedule 1 clause 1C(2) or clause 1C(4) or (6) must - (a) be made in writing; (b) specify - (i) the name and address of the dependant; (ii) the relationship (child or step-child) of the dependant to the deceased worker; (iii) the name of the deceased worker, and the address of the deceased worker at the time of death; (iv) whether the dependant elects to receive an apportionment of the notional residual entitlement or a child's allowance under the Act Schedule 1 clause 1A; (v) whether the worker died leaving any spouse or de facto partner wholly dependent on the workers' earnings, and whether that spouse or de facto partner is a parent of the dependant making the election; (vi) that the dependant has been independently advised of the financial consequences of the election, and the name, title, address and phone number of the person who gave that advice; and (vii) the date on which the election is made; (c) be signed by the dependant or, in the case of an election by a person under a legal disability, the parent or guardian of that person; (d) include the signature and full name and address of a witness to the signature of the dependant or his or her parent or guardian; and (e) be given to the Director. [Regulation 16A inserted in Gazette 28 Oct 2005 p. 4867-8.] 17. Prescribed allowance (clause 11(2)) The Hospital Allowance provided for under the Western Australian Government Health Services (Australian Liquor, Hospitality and Miscellaneous Union) Agreement 2000, or under an industrial award made in replacement of that agreement, is prescribed as an allowance for the purposes of paragraph (c) of the definition of Amount Aa in the Act Schedule 1 clause 11(2). [Regulation 17 inserted in Gazette 21 Jan 2005 p. 275; amended in Gazette 28 Oct 2005 p. 4868.] 17AA. Prescribed rate for vehicle running expenses (clause 19(1)) (1) For the purposes of the Act Schedule 1 clause 19(1), the prescribed rate for vehicle running expenses (irrespective of engine capacity) is - (a) for the period up to and including 30 June 2005, 34 cents per kilometre; and (b) for a financial year commencing on or after 1 July 2005, the amount per kilometre obtained by - (i) varying the amount applying at the end of the preceding financial year by the percentage by which the March CPI varies from the previous March CPI; and (ii) rounding the amount to the nearest whole number of cents (with an amount that is .5 of a cent being rounded off to the next highest whole number of cents). (2) In this regulation - March CPI, for a financial year, means the index number for the quarter ending on the last 31 March before the financial year commences, as shown in the Consumer Price Index Numbers (All Groups Index) for Perth published by the Commonwealth Statistician under the Census and Statistics Act 1905 of the Commonwealth. [Regulation 17AA inserted in Gazette 29 Oct 2004 p. 4939-40; amended in Gazette 28 Oct 2005 p. 4868.] 17AB. Exceptional circumstances (clause 18A(2aa)(c)(ii)) (1) For the purposes of the Act Schedule 1 clause 18A(2aa)(c)(ii) the circumstances in relation to the medical and associated conditions, treatment and management of a worker are exceptional if operative intervention and reasonable post-operative treatment of a kind related to an MBS item are required to alleviate substantially the consequences of serious impairment and improve the worker's physical condition. (2) For the purposes of the Act Schedule 1 clause 18A(2aa)(c)(ii) the applicant must produce the following evidence in writing of the exceptional circumstances - (a) clear medical opinion from a treating specialist that operative intervention and reasonable post-operative treatment of a kind related to an MBS item are required to alleviate the consequences of serious impairment and improve the worker's physical condition; and (b) a management plan provided by the treating specialist that indicates that substantial medical improvement to the worker's physical condition is anticipated as a result of operative intervention and reasonable post-operative treatment. (3) In this regulation - MBS item means an item specified in the Medicare Benefits Schedule published by the Commonwealth Department of Health and Aged Care; treating specialist, in relation to an applicant, means a medical practitioner who - (a) is treating the applicant; and (b) is a specialist in a relevant field of medicine. [Regulation 17AB inserted in Gazette 28 Oct 2005 p. 4868-9; amended in Gazette 18 Nov 2011 p. 4821.] 17AC. Management plan (clause 18A(2ac)) A reference in the Act Schedule 1 clause 18A(2ac) to a management plan is a reference to a management plan produced under regulation 17AB(2)(b). [Regulation 17AC inserted in Gazette 28 Oct 2005 p. 4870.] 17AD. Extending final day (1) A worker may apply to the Director to extend the final day under the Act Schedule 1 clause 18B. (2) The application is made by - (a) lodging with the Director a completed application in the form of Form 31 in Appendix I; and (b) providing to the Director, with the application form, anything that this regulation requires to be provided with the application form. (3) When the application form is lodged - (a) if the worker has, in writing, requested an approved medical specialist to assess the worker's degree of permanent whole of person impairment, the Director must be provided with a copy of the worker's request; and (b) if the approved medical specialist has notified the worker, in writing, that more time is or was required to give the worker the documents required to make an application under the Act Schedule 1 clause 18A(1b) before the final day, the Director must be provided with a copy of the notification. (4) The Director may, within the limits imposed by the Act Schedule 1 clause 18B(4), extend the final day until a day that the Director, having regard to the further time needed by the approved medical specialist, considers will give the worker a reasonable opportunity to make an application under the Act Schedule 1 clause 18A(1b). [Regulation 17AD inserted in Gazette 28 Oct 2005 p. 4870-1.] 17AE. Amount prescribed for funeral expenses (clause 17(2)) (1) For the purposes of the Act Schedule 1 clause 17(2), the amount prescribed for funeral expenses is - (a) for the period up to and including 30 June 2007, $7 547; and (b) for a financial year commencing on or after 1 July 2007, in accordance with section 5A of the Act, the amount obtained by - (i) varying the amount applying at the end of the preceding financial year by the percentage by which the March CPI varies from the previous March CPI; and (ii) rounding the amount to the nearest whole number of cents (with an amount that is .5 of a cent being rounded off to the next highest whole number of cents). (2) In this regulation - March CPI, for a financial year, means the index number for the quarter ending on the last 31 March before the financial year commences, as shown in the Consumer Price Index Numbers (All Groups Index) for Perth published by the Commonwealth Statistician under the Commonwealth Census and Statistics Act 1905. [Regulation 17AE inserted in Gazette 4 Aug 2006 p. 2855-6.] 17A. Supplementary amount (1) The supplementary amount referred to in the Schedule 5 clause 1 of the Act is - (a) for the period up to and including 30 June 2008 - (i) in relation to a worker with a dependant spouse or dependant de facto partner, or both, $228; and (ii) in relation to a worker without a dependant spouse or dependant de facto partner, $128; and (b) for a financial year commencing on or after 1 July 2008, in accordance with section 5A of the Act, the amount obtained by - (i) varying the amount applying at the end of the preceding financial year by the percentage by which the March CPI varies from the previous March CPI; and (ii) rounding the amount to the nearest whole number of cents (with an amount that is 0.5 of a cent being rounded off to the next highest whole number of cents). (2) In this regulation - March CPI, for a financial year, means the index number for the quarter ending on the last 31 March before the financial year commences, as shown in the Consumer Price Index Numbers (All Groups Index) for Perth published by the Commonwealth Statistician under the Commonwealth Census and Statistics Act 1905. [Regulation 17A inserted in Gazette 2 Nov 2007 p. 5933-4.] 17B. Witness allowances A person who appears before the Registrar or an arbitrator to give evidence is entitled to any allowance for that appearance set by the Costs Committee established under section 269 of the Act. [Regulation 17B inserted in Gazette 28 Oct 2005 p. 4871; amended in Gazette 18 Nov 2011 p. 4821.] 18. Form of election to receive redemption amount or supplementary amount (1) The election to receive the redemption amount as a lump sum, referred to in Schedule 5 to the Act shall be in the form of Form 14 in Appendix I. (2) The election to receive the supplementary amount, referred to in Schedule 5 to the Act shall be in the form of Form 15 in Appendix I. [Regulation 18 amended in Gazette 17 Nov 2000 p. 6312.] Part 2A - Assessment of costs [Heading inserted in Gazette 28 Oct 2005 p. 4871.] 18A. Application of this Part This Part applies in relation to any costs incurred on or after 14 November 2005 in relation to a proceeding determined, or otherwise dealt with, by a dispute resolution authority. [Regulation 18A inserted in Gazette 28 Oct 2005 p. 4871.] 18B. Terms used In this Part - agent service has the meaning given to that term in section 261 of the Act; applicant means an applicant for assessment of costs under regulation 18C; application means an application for assessment of costs under regulation 18C; commencement day means the day of the coming into operation of the Workers' Compensation and Injury Management Amendment Act 2011 section 6; dispute resolution authority, in relation to the period commencing on 14 November 2005 and ending on the day before commencement day, has the meaning given in section 5 of the former provisions; former provisions means the Act as enacted before the commencement day; legal service has the meaning given to that term in section 261 of the Act; taxing officer means the Director, the Registrar, a conciliation officer or an arbitrator. [Regulation 18B inserted in Gazette 28 Oct 2005 p. 4872; amended in Gazette 18 Nov 2011 p. 4821.] 18C. Application for assessment of costs (1) A person who has paid or is liable to pay, or who is entitled to receive or who has received, costs as a result of an order for the payment of an unspecified amount of costs made by a dispute resolution authority before commencement day may apply under the Workers' Compensation and Injury Management Arbitration Rules 2011 for an assessment of the whole of, or any part of, those costs by a taxing officer. (2) A person who has paid or is liable to pay, or who is entitled to receive or has received, costs as a result of an order for the payment of an unspecified amount of costs made by a dispute resolution authority on or after commencement day may apply under the Workers' Compensation and Injury Management Conciliation Rules 2011 or the Workers' Compensation and Injury Management Arbitration Rules 2011, as relevant, for an assessment of the whole of, or any part of, those costs by a taxing officer. [Regulation 18C inserted in Gazette 28 Oct 2005 p. 4872; amended in Gazette 18 Nov 2011 p. 4822.] 18D. Taxing officer may require application to be given to other persons (1) A taxing officer may, by written notice, require an applicant to give a copy of the application to - (a) a party to the proceeding in respect of which the relevant order for costs was made; or (b) a legal practitioner, agent or other interested party, specified by the taxing officer. (2) The application must be given in accordance with the Workers' Compensation and Injury Management Conciliation Rules 2011 or the Workers' Compensation and Injury Management Arbitration Rules 2011 as relevant. (3) If a person fails, without reasonable excuse, to comply with a notice given under subregulation (1) the taxing officer may decline to deal with the application. [Regulation 18D inserted in Gazette 28 Oct 2005 p. 4872-3; amended in Gazette 18 Nov 2011 p. 4822.] 18E. Taxing officer may require documents or further particulars (1) A taxing officer may, by written notice, require a person (including the applicant, a party to the proceeding in which the relevant order for costs was made, the legal practitioner or agent concerned or any other legal practitioner or agent) to produce any relevant documents of or held by the person in respect of the matter. (2) A taxing officer may, by written notice, require an applicant to give to the taxing officer further particulars as to any item of costs claimed. (3) A notice given under subregulation (1) or (2) must specify the period within which the notice is to be complied with. (4) If a person fails, without reasonable excuse, to comply with a notice given under subregulation (1) or (2) the taxing officer may decline to deal with the application or may continue to deal with the application on the basis of the information provided. (5) Nothing in this regulation prevents a person from objecting to the production of a document on the grounds of legal professional privilege. [Regulation 18E inserted in Gazette 28 Oct 2005 p. 4873.] 18F. Consideration of application (1) A taxing officer must not determine an application unless the taxing officer - (a) has given the applicant and any other party to the proceeding in which the relevant order for costs was made a reasonable opportunity to make oral or written submissions in relation to the application; and (b) has given due consideration to any submissions so made. (2) In considering an application a taxing officer is not bound by the rules of evidence and may inform himself or herself on any matter in such manner as the taxing officer thinks fit. [Regulation 18F inserted in Gazette 28 Oct 2005 p. 4874.] 18G. Assessment to give effect to order and costs determination An assessment of costs must be made in accordance with, and so as to give effect to, orders of the dispute resolution authority and any costs determination published under section 273 of the Act. [Regulation 18G inserted in Gazette 28 Oct 2005 p. 4874.] 18H. Matters to be considered (1) When dealing with an application the taxing officer must consider - (a) whether or not it was reasonable to carry out the work to which the costs relate; and (b) what is a fair and reasonable amount of costs for the work concerned. (2) In assessing what is a fair and reasonable amount of costs, the taxing officer may have regard to any or all of the following matters - (a) the skill, labour and responsibility displayed on the part of the legal practitioner or agent responsible for the matter; (b) the complexity, novelty or difficulty of the matter; (c) the quality of the work done and whether the level of expertise was appropriate to the nature of the work done; (d) the place where and circumstances in which the legal services or agent services were provided; (e) the time within which the work was required to be done; (f) the outcome of the matter. (3) If the dispute resolution authority has ordered that the costs are to be assessed on a specified basis, the taxing officer must assess the costs on that basis. [Regulation 18H inserted in Gazette 28 Oct 2005 p. 4874-5.] 18I. Cost of assessment The costs of and incidental to an assessment are at the discretion of the taxing officer. [Regulation 18I inserted in Gazette 28 Oct 2005 p. 4875.] 18J. Enforcement of assessment (1) The taxing officer must issue to each party a certificate that sets out the amount in which costs have been assessed and allowed by the taxing officer. (2) The costs are payable under the order made by the dispute resolution authority as to the costs. [Regulation 18J inserted in Gazette 28 Oct 2005 p. 4875.] 18K. Correction of error At any time after making a determination a taxing officer who made the determination may, for the purpose of correcting an inadvertent error in the determination - (a) make a new determination in substitution for the previous determination; and (b) issue a certificate under regulation 18J that sets out the new determination. [Regulation 18K inserted in Gazette 28 Oct 2005 p. 4876.] 18LA. Transitional provision (1) In this regulation - pending application means an application for the assessment of costs by a taxing officer - (a) made under the Workers' Compensation (DRD) Rules 2005 before commencement day; and (b) which has not been determined by a taxing officer before commencement day. (2) A pending application is to be dealt with and determined under this Part as if it were an application made under the Workers' Compensation and Injury Management Arbitration Rules 2011. [Regulation 18LA inserted in Gazette 18 Nov 2011 p. 4822-3.] Part 2B - Medical assessment [Heading inserted in Gazette 28 Oct 2005 p. 4876.] 18L. Terms used In this Part - prescribed details, in relation to a worker, means - (a) the worker's name and address and any other details necessary to identify the worker; (b) details sufficient to enable the worker to be contacted; (c) the worker's date of birth; (d) the date on which the worker's injury occurred; (e) a description of the worker's injury; (f) if a claim for compensation has been made under the Act with respect to the worker's injury - details sufficient to identify the claim, including any claim number that has been given to the claim; (g) the employer's name and address and any other details necessary to identify the employer; (h) details sufficient to enable the employer to be contacted; and (i) the insurer's name, if any; relevant provisions of the Act means - (a) Part III Division 2A of the Act (which provides for lump sum payments for specified injuries); (b) Part IV Division 2 Subdivision 3 of the Act (which provides for restrictions on awarding, and the amount of, damages); (c) Part IXA of the Act (which provides for specialised retraining programs); or (d) (except in regulation 18R(3)(e)) clause 18A of Schedule 1 to the Act (which provides for additional sums to be allowed for medical expenses). [Regulation 18L inserted in Gazette 28 Oct 2005 p. 4876-7.] 18M. Request for assessment by approved medical specialist of worker's degree of impairment For the purposes of section 146A(3) of the Act, a request for a worker's degree of impairment to be assessed by an approved medical specialist has to be given in writing to the approved medical specialist, specifying - (a) the prescribed details in relation to the worker; (b) the approved medical specialist's name; (c) the relevant provisions of the Act for the purposes of which the assessment is to be made; and (d) the date of the request for the assessment. [Regulation 18M inserted in Gazette 28 Oct 2005 p. 4877.] 18N. Requirement to attend at place specified by approved medical specialist For the purposes of section 146G(1)(a) of the Act, the requirement for a worker to attend at a place specified by an approved medical specialist - (a) has to be given in writing to the worker and sent to the worker's address specified in the request for assessment referred to in regulation 18M; and (b) has to specify - (i) the prescribed details in relation to the worker; (ii) the approved medical specialist's name; (iii) details sufficient to enable the approved medical specialist to be contacted; (iv) the relevant provisions of the Act for the purposes of which the assessment is to be made; and (v) the time when and the place where the worker is to submit to examination, as required under section 146G(1)(d) of the Act. [Regulation 18N inserted in Gazette 28 Oct 2005 p. 4878.] 18O. Requirement to produce to approved medical specialist relevant documents and information and give consent (1) For the purposes of section 146G(1)(c)(i) of the Act, the requirement to produce to an approved medical specialist any relevant document or information has to be given in writing to the worker, the employer, or the employer's insurer, specifying - (a) the prescribed details in relation to the worker; (b) details of any relevant document or information to which the requirement applies; (c) the approved medical specialist's name; (d) details sufficient to enable the approved medical specialist to be contacted; and (e) the relevant provisions of the Act for the purposes of which the assessment is to be made. (2) For the purposes of section 146G(1)(c)(ii) of the Act, the requirement to consent to another person who has any relevant document or information producing it to an approved medical specialist has to be given in writing to the worker, the employer, or the employer's insurer, specifying - (a) the prescribed details in relation to the worker; (b) details of any relevant document or information to which the requirement applies; (c) the name of the person who has the relevant document or information; (d) the approved medical specialist's name; (e) details sufficient to enable the approved medical specialist to be contacted; and (f) the relevant provisions of the Act for the purposes of which the assessment is to be made. [Regulation 18O inserted in Gazette 28 Oct 2005 p. 4878-9.] 18P. Period for compliance with requirements If the time for complying with a requirement referred to in regulation 18O is not specified in the requirement, the requirement has to be complied with within 7 days after the day on which the person who is to comply with the requirement receives it. [Regulation 18P inserted in Gazette 28 Oct 2005 p. 4879.] 18Q. Requirement for worker to produce requested information (1) On being requested in writing to do so by the approved medical specialist, a worker who has requested an approved medical specialist to assess his or her degree of impairment is required to produce to the approved medical specialist for use in dealing with the requested assessment, within 7 days after the day on which the worker receives the approved medical specialist's request, any information that - (a) relates to the injury from which the impairment resulted; and (b) is specified in the approved medical specialist's request. (2) A request by an approved medical specialist under subregulation (1) has to include - (a) the approved medical specialist's name; and (b) details sufficient to enable the approved medical specialist to be contacted. (3) A person who contravenes a requirement under subregulation (1) commits an offence and is liable to a fine of $2 000. (4) Subregulation (1) does not apply to any information that is the subject of a requirement referred to in regulation 18O(1). [Regulation 18Q inserted in Gazette 28 Oct 2005 p. 4880.] 18R. Reports and certificates regarding outcome of assessment (1) A report of a worker's degree of impairment given by an approved medical specialist under section 146H(1)(a) of the Act has to include - (a) the prescribed details in relation to the worker; (b) the approved medical specialist's name; (c) details sufficient to enable the approved medical specialist to be contacted; (d) the date of the examination of the worker by, or at the request of, the approved medical specialist; and (e) the relevant provisions of the Act for the purposes of which the assessment was made. (2) A certificate specifying a worker's degree of impairment given by an approved medical specialist under section 146H(1)(b) of the Act has to include - (a) the prescribed details in relation to the worker; (b) the approved medical specialist's name; (c) details sufficient to enable the approved medical specialist to be contacted; and (d) the date of the examination of the worker by, or at the request of, the approved medical specialist. (3) A report given by an approved medical specialist under section 146H(2)(c) of the Act has to include - (a) the prescribed details in relation to the worker; (b) the approved medical specialist's name; (c) details sufficient to enable the approved medical specialist to be contacted; (d) the date of the examination of the worker by, or at the request of, the approved medical specialist; and (e) the relevant provisions of the Act for the purposes of which the relevant certificate under section 146H(2) of the Act was given. [Regulation 18R inserted in Gazette 28 Oct 2005 p. 4880-1.] 18S. Requirement to attend at place specified by approved medical specialist panel For the purposes of section 146L(2)(a) of the Act, the requirement for a worker to attend at a place specified by an approved medical specialist panel has to be given in writing to the worker, specifying - (a) the prescribed details in relation to the worker; (b) the names of the members of the approved medical specialist panel; and (c) the time when and the place where the worker is to submit to examination, as required under section 146L(2)(d) of the Act. [Regulation 18S inserted in Gazette 28 Oct 2005 p. 4882.] 18T. Requirement to produce to approved medical specialist panel relevant documents and information and give consent (1) For the purposes of section 146L(2)(c)(i) of the Act, the requirement to produce to an approved medical specialist panel any relevant document or information has to be given in writing to the worker, the employer, or the employer's insurer, specifying - (a) the prescribed details in relation to the worker; (b) details of any relevant document or information to which the requirement applies; and (c) the names of the members of the approved medical specialist panel. (2) For the purposes of section 146L(2)(c)(ii) of the Act, the requirement to consent to another person who has any relevant document or information producing it to an approved medical specialist panel has to be given in writing to the worker, the employer, or the employer's insurer, specifying - (a) the prescribed details in relation to the worker; (b) details of any relevant document or information to which the requirement applies; (c) the name of the person who has the relevant document or information; and (d) the names of the members of the approved medical specialist panel. [Regulation 18T inserted in Gazette 28 Oct 2005 p. 4882-3.] 18U. Period for compliance with requirements If the time for complying with a requirement referred to in regulation 18T is not specified in the requirement, the requirement has to be complied with within 7 days after the day on which the person who is to comply with the requirement receives it. [Regulation 18U inserted in Gazette 28 Oct 2005 p. 4883.] 18V. Requirement for worker to produce requested information (1) On being requested to do so by the approved medical specialist panel, a worker in respect of whom a question as to degree of impairment has been referred to an approved medical specialist panel is required to produce to the approved medical specialist panel for use in dealing with the referral, within 7 days after the day on which the worker receives the request, any information that - (a) relates to the injury from which the impairment resulted; and (b) is specified in the approved medical specialist panel's request. (2) A request by an approved medical specialist panel under subregulation (1) has to include the names of the members of the approved medical specialist panel. (3) A person who contravenes a requirement under subregulation (1) commits an offence and is liable to a fine of $2 000. (4) Subregulation (1) does not apply to any information that is the subject of a requirement referred to in regulation 18T(1). [Regulation 18V inserted in Gazette 28 Oct 2005 p. 4883-4.] 18W. Reports and certificates regarding outcome of assessment A report of a worker's degree of impairment given by an approved medical specialist panel under section 146O(2)(a) of the Act, or a certificate specifying a worker's degree of impairment given by an approved medical specialist panel under section 146O(2)(b) of the Act, has to include - (a) the prescribed details in relation to the worker; (b) the names of the members of the approved medical specialist panel; and (c) the date of the examination of the worker by, or at the request of, the members of the approved medical specialist panel. [Regulation 18W inserted in Gazette 28 Oct 2005 p. 4884.] [19. Deleted in Gazette 8 Mar 2002 p. 949.] Part 3 - Noise induced hearing loss [Heading inserted in Gazette 26 Feb 1991 p. 934.] 19A. Terms used In this Part unless the contrary intention appears - approved means approved in writing by the chief executive officer; approved medical practitioner means a medical practitioner approved under regulation 19B(1)(a); approved person means a person approved under regulation 19B; audiologist means an audiologist approved under regulation 19B(1)(b); audiometric officer means a person approved under regulation 19B(1)(c); Australian Standard means a standard published by the Standards Association of Australia 3, as amended from time to time; clause means a clause in the Act Schedule 7. [Regulation 19A inserted in Gazette 26 Feb 1991 p. 934; amended in Gazette 21 Jan 2005 p. 276; 28 Oct 2005 p. 4884.] 19B. Persons approved to carry out audiometric testing (1) The chief executive officer may approve, either generally or in a particular case, the following persons to carry out audiometric testing - (a) a medical practitioner; (b) an audiologist who is either a full member or qualified to be a full member of the Audiological Society of Australia; and (c) a person who, in the opinion of the chief executive officer, has appropriate qualifications to enable that person to carry out audiometric testing as an audiometric officer. (2) An audiometric test for the purposes of sections 24A and 24B of the Act shall be carried out by a person approved under subregulation (1). (3) The chief executive officer may at any time cancel an approval given under subregulation (1). (4) The chief executive officer shall serve on each person to whom an approval, or cancellation of approval, relates a certificate of approval or notification of cancellation, as the case requires. [Regulation 19B inserted in Gazette 26 Feb 1991 p. 934; amended in Gazette 21 Jan 2005 p. 276.] 19C. Testing procedures (1) An approved person shall carry out an audiometric test - (a) using an audiometer which meets the standards specified in writing by the chief executive officer; and (b) in an approved hearing booth or other approved testing environment. (2) An approved person using an audiometer under subregulation (1) shall - (a) check the audiometer on each day of use, both before and after the series of measurements carried out and after any relocation of the audiometer, to ensure that the audiometer is in satisfactory working order; and (b) ensure that the audiometer has been calibrated at an approved calibration laboratory within the 12 months preceding each day of use and that the audiometric officer has received a copy of the report prepared on that calibration. (3) An approved person shall ensure that the background noise levels during the testing of the hearing of a worker do not exceed those values listed in Table 5.1 in Section 5 of Australian Standard 1269-1989, or an approved equivalent, for the type of earphone/cushion or earphone enclosure combination connected to the audiometer used for the testing. (4) Subject to subregulation (5), an approved person shall test the hearing of a worker by means of a pure tone air conduction hearing threshold test carried out separately for the left and right ears - (a) in accordance with - (i) the procedure described in Section E2 of Appendix E of Australian Standard 1269-1989 as modified by written direction of the chief executive officer; or (ii) any procedure which establishes a higher testing procedure than that specified in subparagraph (i) and which is approved in writing by the chief executive officer; and (b) if the test is conducted in accordance with the procedure referred to in paragraph (a)(i), at the frequencies 500, 1 000, 1 500, 2 000, 3 000, 4 000, 6 000, 8 000 Hz except that where an audiometer does not possess a 1 500 Hz tone the hearing threshold for that frequency shall be calculated by drawing a straight line on an audiogram connecting the points of threshold for 1 000 and 2 000 Hz, marking the point of intersection with the 1 500 Hz line, and adjusting this value to the nearest 5dB increment. (5) If, in the opinion of the chief executive officer, a worker has an injury which will prevent the effective use of an audiometric test referred to in subregulation (4), the hearing of that worker may be tested by any other method approved for the purposes of this subregulation. (6) In instances where audiometric testing is carried out by an audiometric officer and the audiometric officer believes that the worker meets the criteria specified in Item 4 of Waugh & Macrae's criteria for medical referral in Table 1 of National Acoustic Laboratories Report No. 80 "Criteria for assessing hearing conservation audiograms", the audiometric officer shall refer the worker to a medical practitioner and the audiometric officer shall defer audiometric testing until the worker has complied with the referral and the audiometric officer is satisfied that the worker does not meet those criteria. (7) Where an initial audiometric test is carried out by an audiometric officer and the results of an air conduction test meet the criteria specified in Item 1, 2 or 3 of Waugh and Macrae's criteria for medical referral in Table 1 of National Acoustic Laboratories Report No. 80, the audiometric officer shall refer the worker to an audiologist or an approved medical practitioner for full audiometric testing. (8) Where the results of an air conduction test carried out after an initial audiometric test show - (a) at least a 10% loss of hearing from the initial audiometric test; (b) at least a 5% loss of hearing from the loss shown by the audiometric test which resulted in a successful election by the worker under section 24A or 31E of the Act; or (c) where the worker has reached the age of 65 years or on the worker's retirement from work before that age, any further percentage loss of hearing from the loss shown by the audiometric test which resulted in a successful election by the worker under section 24A or 31E of the Act, the worker shall be referred by WorkCover WA to an audiologist or an approved medical practitioner for full audiometric testing, and the audiologist or medical practitioner shall, upon completion of that testing refer the worker to a medical practitioner registered in the specialty of otorhinolaryngology for full otorhinolaryngological assessment to determine the percentage of noise induced hearing loss. (9) Where the results of a further air conduction test, carried out after those tests referred to in subregulation (8), show a further loss of hearing, the worker shall be referred by WorkCover WA to an audiologist or an approved medical practitioner for full audiometric testing and the audiologist or medical practitioner shall, if a further hearing loss is confirmed, refer the worker to a medical practitioner registered in the speciality of otorhinolaryngology for a full otorhinolaryngological assessment to determine the percentage of noise induced hearing loss. (10) Where a worker is referred to an approved medical practitioner, audiologist or medical practitioner registered in the speciality of otorhinolaryngology under subregulation (6), (7), (8) or (9), the audiometric test of that worker is completed on the date that - (a) if the referral is under subregulation (6), the audiometric officer completes the audiometric test; (b) if the referral is under subregulation (7), the medical practitioner or audiologist completes the audiometric test; and (c) if the referral is under subregulation (8) or (9), the medical practitioner or audiologist completes the audiometric test, or if the worker is further referred, the medical practitioner registered in the speciality of otorhinolaryngology determines the percentage of noise induced hearing loss. [Regulation 19C inserted in Gazette 26 Feb 1991 p. 935-7; amended in Gazette 3 Apr 1992 p. 1541-2; 24 Dec 1993 p. 6845; 17 Nov 2000 p. 6312; 21 Jan 2005 p. 276; 28 Oct 2005 p. 4884-5.] 19D. Notice of audiometric test and testing arrangements (1) The employer of a worker who is required, or who makes a request, to undergo an audiometric test under clause 2 shall give written notice of the test to the worker in the form of Form 18 in Appendix I. (2) The employer of a worker given a notice under subregulation (1) shall ensure that the worker is not knowingly exposed in the workplace, and the worker shall not knowingly permit himself to be exposed, to noise levels above 80dB(A) during the 16 hours preceding an audiometric test. (3) A worker given a notice under subregulation (1) shall not, without reasonable excuse, proof of which is on the worker, fail to submit himself for testing so notified. [Regulation 19D inserted in Gazette 26 Feb 1991 p. 937; amended in Gazette 17 Nov 2000 p. 6312.] 19E. Calculation of loss of hearing (1) In sections 24A(2) and 31E(3) of the Act, loss of hearing means loss of hearing calculated in accordance with the hearing loss tables RB and EB published in Appendices 3 and 7 of Report No. 118 of the National Acoustic Laboratories as annexed in Appendix III. (2) The method of determining percentage loss of hearing occurring during the interval between 2 audiometric tests shall be by subtraction. [Regulation 19E inserted in Gazette 26 Feb 1991 p. 937; amended in Gazette 28 Oct 2005 p. 4885.] 19F. Report on audiometric test and storage of results (1) A person who carries out an audiometric test shall ensure that the results are prepared and delivered to WorkCover WA and the worker in the form of Form 19A or Form 19B in Appendix I, as the case requires. (2) WorkCover WA shall, on the written request of the worker tested, communicate the results of an audiometric test delivered to it under clause 4(2) to any person specified by the worker in that request. (3) A person who receives the results of an audiometric test under subregulation (2) shall ensure that the results of the test, and any information derived from those results are not communicated to any person other than the worker except at the written request of the worker tested. Penalty: a fine of $1 000. (4) WorkCover WA shall store the results of audiometric tests delivered to it under clause 4(2) for a period ending the day after the 70th birthday of the worker to whom the results relate. [Regulation 19F inserted in Gazette 26 Feb 1991 p. 937-8; amended in Gazette 17 Nov 2000 p. 6312; 21 Jan 2005 p. 276; 28 Oct 2005 p. 4885.] [19G. Deleted in Gazette 28 Oct 2005 p. 4885.] 19H. Retest of person's hearing (1) A worker or employer who disputes the results of an audiometric test shall give notice in the form of Form 21 in Appendix I to WorkCover WA. (2) A retest of a worker's hearing under clause 7(1) shall be carried out in the manner prescribed under regulation 19C by - (a) an approved medical practitioner; (b) an audiologist; or (c) a medical practitioner registered in the speciality of otorhinolaryngology, nominated in writing by the chief executive officer. (3) A retest of a worker's hearing under clause 7(1) may include - (a) a physical examination; and (b) any other appropriate investigation the approved medical practitioner or audiologist considers necessary to determine - (i) whether the worker's hearing loss is noise induced; (ii) whether the worker's hearing loss is due, or partly due, to ear disease; (iii) whether the worker's hearing loss is due, or partly due, to a hearing loss which is noise induced but of a type which is not due to the nature of any employment in which the worker was or is engaged; and (iv) any other causes of the hearing loss. (4) Having regard to the results obtained under subregulation (3), the medical practitioner registered in the speciality of otorhinolaryngology may determine the noise induced hearing loss of the worker as a binaural noise induced hearing loss expressed as a percentage loss of hearing. [Regulation 19H inserted in Gazette 26 Feb 1991 p. 938-9; amended in Gazette 21 Jan 2005 p. 276.] 19I. Prescribed workplaces (1) For the purposes of clause 10 a prescribed workplace is a workplace or part of a workplace where a worker is receiving, or is likely to receive, noise above the action level specified in subregulation (2). (2) For the purposes of this regulation - action level means - (a) an L peak of 140dB(lin); or (b) a representative LAeq,8h of 90dB(A); L peak means the maximum unweighted sound pressure level recorded with an instrument equipped for measuring peak values in accordance with AS 1259.1-1990; representative LAeq,8h means an 8 hour equivalent continuous A weighted sound pressure level, determined from the assessment of worker exposures that is typical of the operation, work pattern or process being assessed as described in AS 1269-1989 Clause 1.4.7. [Regulation 19I inserted in Gazette 26 Feb 1991 p. 939.] Part 3A - Constraints on awards of common law damages [Heading inserted in Gazette 15 Oct 1999 p. 4890.] Division 1 - 1993 scheme [Heading inserted in Gazette 28 Oct 2005 p. 4885.] 19IA. Guides for assessing degree of disability (1) The first edition is prescribed for the purposes of the definition of AMA Guides in section 93CA of the Act. (2) To the extent, if any, that neither section 93D(2)(a) nor (b) of the Act applies to the assessment of the degree of disability of a worker for the purposes of section 93E, the degree of disability is to be assessed in accordance with the American Medical Association's Guides to the Evaluation of Permanent Impairment (4th Edition). [Regulation 19IA inserted in Gazette 17 Nov 2000 p. 6312-13; amended in Gazette 28 Oct 2005 p. 4885.] 19J. Assessment of degree of disability (1) Subject to regulations 19JA and 19JB, a referral under section 93D(5) of the Act - (a) is to be made in the form of Form 22 in Appendix I; and (b) is to nominate one, and only one, relevant level of the degree of disability in respect of which the referral is made. (2) A notification under section 93D(7) of the Act is to be - (a) made in the form of Form 23 in Appendix I; and (b) accompanied by a copy of the medical evidence produced to the Director under section 93D(6) of the Act. (3) Subject to regulations 19JA and 19JB, a notification under section 93D(8) of the Act is to be made in the form of Form 23 in Appendix I. [Regulation 19J inserted in Gazette 15 Oct 1999 p. 4890-1; amended in Gazette 14 Dec 1999 p. 6147; 26 Oct 2004 p. 4899; 28 Oct 2005 p. 4886 and 4911.] 19JA. Method of referral and notification when section 93EA(3) of the Act applies (1) A referral under section 93D(5) of the Act in combination with section 93EA(3) of the Act (due to the application of section 93EA(3) of the Act) is to be made in the form of Appendix I Form 22A. (2) When completing Form 22A, the worker is to nominate one, and only one, relevant level of the degree of disability in respect of which the referral is made, and provide details of the medical evidence relied upon to support the referral. (3) If section 93EA(3) of the Act applies because of a referral that was made before 14 December 1999 and, in that earlier referral - (a) the worker nominated both relevant levels of the degree of disability on the same form; and (b) the worker is still seeking to nominate both relevant levels of the degree of disability in the present referral, the worker is to complete a separate Form 22A for each of the previously nominated relevant levels of the degree of disability. (4) A notification under section 93EA(5)(a) and (b)(i) of the Act is to be given in the form of Appendix I Form 23A. (5) The Director is to include a copy of any medical evidence that was produced and that complies with section 93D(6) of the Act, when giving notification under subregulation (4). (6) A notification under section 93D(8) of the Act that relates to a referral under section 93D(5) of the Act, due to the application of section 93EA(3) of the Act, is to be made in the form of Appendix I Form 23A. (7) A notification under section 93EA(5)(b)(ii) of the Act is to be given in writing. [Regulation 19JA inserted in Gazette 26 Oct 2004 p. 4899-900; amended in Gazette 28 Oct 2005 p. 4911.] 19JB. Method of referral and notification when section 93EB(3) of the Act applies (1) A referral under section 93D(5) of the Act in combination with section 93EB(3) of the Act (due to the application of section 93EB(3) of the Act) is to be made in the form of Appendix I Form 22B. (2) When completing Form 22B, the worker is to nominate one, and only one, relevant level of the degree of disability in respect of which the referral is made, and provide details of the medical evidence relied upon to support the referral. (3) If section 93EB(3) of the Act applies because of a referral that was made before 14 December 1999 and, in that earlier referral - (a) the worker nominated both relevant levels of the degree of disability on the same form; and (b) the worker is still seeking to nominate both relevant levels of the degree of disability in the present referral, the worker is to complete a separate Form 22B for each of the previously nominated relevant levels of the degree of disability. (4) A notification under section 93EB(5)(a) and (b)(i) of the Act is to be given in the form of Appendix I Form 23B. (5) The Director is to include a copy of any medical evidence that was produced and that complies with section 93D(6) of the Act, when giving notification under subregulation (4). (6) A notification under section 93D(8) of the Act that relates to a referral under section 93D(5) of the Act, due to the application of section 93EB(3) of the Act, is to be made in the form of Appendix I Form 23B. (7) A notification under section 93EB(5)(b)(ii) of the Act is to be given in writing. [Regulation 19JB inserted in Gazette 26 Oct 2004 p. 4900-1; amended in Gazette 28 Oct 2005 p. 4911.] 19K. Agreement as to degree of disability (1) An agreement as to the level of the degree of disability for the purposes of section 93E(3)(a), (4) or (9) of the Act is to be made in the form of Form 24 in Appendix I and lodged with the Director. (2) On receipt of the agreement the Director is to - (a) record the agreement in a register kept for that purpose; and (b) complete the relevant section of the agreement form and give a copy of it to the worker and the employer. [Regulation 19K inserted in Gazette 15 Oct 1999 p. 4891; amended in Gazette 28 Oct 2005 p. 4886.] 19L. Determination of degree of disability (1) The Director is to be notified as soon as practicable after the determination of - (a) a dispute that arises under section 93D(8) of the Act; or (b) a question referred to a medical panel under section 93D(11) of the Act. (2) Upon becoming aware of a determination described in subregulation (1), the Director is to, as soon as practicable - (a) record the determination in a register kept for that purpose; and (b) give a copy of the determination to the worker, the employer and the employer's insurer advising that the determination has been recorded. [Regulation 19L inserted in Gazette 15 Oct 1999 p. 4891; amended in Gazette 17 Nov 2000 p. 6313; 28 Oct 2005 p. 4886; 18 Nov 2011 p. 4823.] 19M. Election to retain right to seek common law damages (1) An election under section 93E(3)(b) of the Act - (a) is made by completing an election form in the form of Form 25 in Appendix I and lodging it with the Director; and (b) cannot be made unless - (i) it is agreed that the degree of disability is not less than 16%; or (ii) it is determined that the degree of disability is not less than 16%. (2) If it is agreed that the degree of disability is not less than 16% the election form is to be accompanied by Form 24 in Appendix I unless an agreement as to the degree of disability for the purposes of section 93E(3)(a), (4) or (9) of the Act was recorded under regulation 19K before the lodgment of the election form. (3) If it is determined that the degree of disability is not less than 16% the election form is to be accompanied by evidence of the determination unless a determination of a dispute as to the degree of disability was recorded under regulation 19L before the lodgment of the election form. (4) Subject to subregulation (5), on the day on which the Director receives the election form the Director is to - (a) record - (i) under regulation 19K(2)(a) the agreement (if any) accompanying the election form; or (ii) under regulation 19L(2)(a) the determination (if any) accompanying the election form; (b) register the election in a register kept for that purpose; and (c) complete the relevant section of the election form and give a copy of it to the worker and the employer. (5) The Director may refuse to register an election if not satisfied that the worker has been properly advised of the consequences of the election. (6) This regulation applies to an election under section 93E(3)(b) of the Act that is commenced on or after the day on which the Workers' Compensation and Rehabilitation Amendment Regulations (No. 11) 1999 come into operation 1. [Regulation 19M inserted in Gazette 14 Dec 1999 p. 6147-8; amended in Gazette 17 Nov 2000 p. 6313-14.] 19N. Extension of time to make election under section 93E(3)(b) (1) In this regulation - extension period means the period of time that ends 6 months after the termination day; termination day has the meaning that it has in section 93E of the Act. (2) For the purposes of section 93E(7) of the Act, the circumstances in which the Director may extend the period of time within which an election can be made under section 93E(3)(b) of the Act exist, whether or not the period being extended has already expired, if - (a) the Director is satisfied that the worker will require major surgery in respect of the injury in the extension period; (aa) upon an application described in subregulation (3a), the Director is satisfied that an extension should be given for a period ending not more than 8 weeks after the termination day to give time for a specialist in a relevant field of medicine to prepare a report, based on treatment or medical investigation of the worker, as to whether the worker will require major surgery in respect of the injury in the extension period; (b) no extension has been given under paragraph (aa) and the Director is satisfied that medical evidence that the worker will require major surgery in respect of the injury in the extension period has not been obtained from a medical practitioner who is a specialist in a relevant field of medicine despite all reasonably practicable steps having been taken by or on behalf of the worker to obtain that evidence; or (c) the Director is satisfied that a medical panel under section 36 of the Act has determined that the worker's injury is of a kind mentioned in section 33 or 34 of the Act. (3) An application for an extension of time under subregulation (2)(a) is to be - (a) made in the form of Form 26 in Appendix I; (b) accompanied by medical evidence from a medical practitioner who is a specialist in a relevant field of medicine; and (c) lodged with the Director at least 21 days before - (i) the termination day; or (ii) if an extension of time has been granted under subregulation (2)(aa) or (b), the last day of the period as extended. (3a) An application for an extension of time under subregulation (2)(aa) to give time for the preparation of a specialist's report, based on treatment or medical investigation of the worker, is to be - (a) made in the form of Form 28 in Appendix I; (b) accompanied by medical evidence from a specialist in a relevant field of medicine indicating that - (i) a report could not be satisfactorily prepared without the treatment or investigation having been carried out; and (ii) the extension sought is needed to give sufficient time for the preparation of the report; and (c) lodged with the Director at least 21 days before the termination day. (4) An application for an extension of time under subregulation (2)(b) is to be - (a) made in the form of Form 27 in Appendix I; (b) accompanied by such evidence, in addition to that provided in the Form 27, as may be requested by the Director about - (i) the requirement for the worker to have the surgery mentioned in subregulation (2)(b); or (ii) the action taken by or on behalf of the worker to obtain the medical evidence mentioned in subregulation (2)(b); and (c) lodged with the Director at least 21 days before the termination day. (5) An application for an extension of time under subregulation (2)(c) is to be - (a) made in the form of Form 26 in Appendix I; (b) accompanied by evidence of the medical panel's determination; and (c) lodged with the Director at least 21 days before - (i) the termination day; or (ii) if an extension of time has been granted under subregulation (2)(aa) or (b), the last day of the period as extended. (6) Within 14 days of receiving the application the Director is to - (a) decide whether to extend the period within which the election can be made; (b) set the extension period in accordance with section 93E(7); and (c) complete the relevant section of the application form and give a copy of it to the worker and the employer. [Regulation 19N inserted in Gazette 14 Dec 1999 p. 6149-50; amended in Gazette 17 Nov 2000 p. 6314-16; 28 Oct 2005 p. 4911.] 19O. Application for compensation An application for compensation under section 93E(11) of the Act is to be made and dealt with in accordance with the Workers' Compensation and Injury Management Conciliation Rules 2011 or the Workers' Compensation and Injury Management Arbitration Rules 2011, as relevant, as if it were an application in respect of a dispute as to the amount of compensation. [Regulation 19O inserted in Gazette 15 Oct 1999 p. 4892; amended in Gazette 28 Oct 2005 p. 4886; 18 Nov 2011 p. 4823.] 19P. Notification to workers about elections as to common law damages (1) The employer of a worker who has an unfinalised claim for compensation under the Act is to give the worker written notice, in a form approved by the chief executive officer, of - (a) the requirement under section 93E(3)(b) of the Act for the worker to elect to retain the right to seek damages; and (b) the date by which the election is to be made. (2) The employer is to give the notice mentioned in subregulation (1) - (a) if a dispute resolution authority orders that weekly payments of compensation are to commence, within 7 days of the day of the order; or (b) in any other case, 3 and 5 months from the day on which weekly payments commenced. (3) An employer's obligation under this regulation to give a worker notice is fulfilled if the notice is given, within the time required, by an insurer with which the employer has a policy indemnifying the employer against liability to pay the compensation claimed. [Regulation 19P inserted in Gazette 14 Dec 1999 p. 6150-1; amended in Gazette 17 Nov 2000 p. 6316-17; 21 Jan 2005 p. 276; 28 Oct 2005 p. 4886.] Division 2 - 2004 scheme [Heading inserted in Gazette 28 Oct 2005 p. 4887.] 20. Recording agreement (1) If - (a) the worker and the employer agree - (i) that the worker's degree of permanent whole of person impairment is at least 15%; and (ii) as to whether or not the worker's degree of permanent whole of person impairment is at least 25%; and (b) the worker, in writing, requests the Director to record the agreement, the Director is required to record the agreement in a register kept for the purpose unless an agreement or assessment as to the worker's degree of permanent whole of person impairment has already been recorded under this regulation or regulation 21. (2) The request under subregulation (1)(b) for the Director to record the agreement has to include - (a) the worker's name and any other details necessary to identify the worker; (b) details sufficient to enable the worker to be contacted; (c) the worker's date of birth; (d) the date on which the injury occurred and a description of the injury; (e) if a claim for compensation under the Act for the injury has been made, the date on which the worker's claim was made and sufficient other details to identify the claim (including any claim number that may have been given to the claim); (f) the employer's name and any other details necessary to identify the employer; (g) details sufficient to enable the employer to be contacted; and (h) the name of the insurer, if any. (3) The Director's record in the register is to be in the form of Form 32 in Appendix I, and the Director is required to give a copy of the record to each of the worker and the employer. [Regulation 20 inserted in Gazette 28 Oct 2005 p. 4887-8.] 21. Recording assessment (1) If - (a) the worker's degree of permanent whole of person impairment has been assessed to be a percentage that is not less than 15%; (b) the Director has been given - (i) a copy of the certificate given to the worker under section 146H(1)(b) of the Act; and (ii) if the assessment involves a special evaluation as defined in section 146C(4) of the Act, a copy of the certificate referred to in section 93N(1) of the Act on the basis of which the special evaluation was requested; and (c) the worker, in writing, requests the Director to record the assessment, the Director is required to record the assessment in a register kept for the purpose unless an agreement or assessment as to the worker's degree of permanent whole of person impairment has already been recorded under regulation 20 or this regulation. (2) The Director's record in the register is to be in the form of Form 33 in Appendix I, and the Director is required to give a copy of the record to each of the worker and the employer. [Regulation 21 inserted in Gazette 28 Oct 2005 p. 4888-9.] 22. Electing to retain right to seek damages (1) An election under section 93K(4)(a) of the Act is made by completing an election form in the form of Form 34 in Appendix I and lodging it with the Director. (2) Unless under subregulation (3) the Director refuses to register the election, the Director is to - (a) register the election in a register kept for that purpose on the day on which the Director receives the election form; and (b) complete the relevant section of the election form and give a copy of it to the worker and the employer. (3) The Director may refuse to register the election if not satisfied that the worker has been properly advised of the consequences of the election. [Regulation 22 inserted in Gazette 28 Oct 2005 p. 4889.] 23. Extending termination day (1) A worker may apply for the Director to extend the termination day under section 93M of the Act. (2) The application is made by - (a) lodging with the Director a completed application form in the form of Form 35 in Appendix I; and (b) providing to the Director, with the application form, anything that this regulation requires to be provided with the application form. (3) If the application is made in the circumstances described in section 93M(4)(a) of the Act - (a) when the application form is lodged, the Director has to be provided with - (i) a copy of the approved medical specialist's certificate certifying that the worker's condition has not stabilised to the extent required for a normal evaluation of the worker's degree of permanent whole of person impairment to be made in accordance with the WorkCover Guides as described in sections 146A and 146C of the Act; (ii) a copy of the approved medical specialist's recommendation of a day until which the termination day be extended; and (iii) a copy of the approved medical specialist's report under section 146H(2)(c) of the Act; and (b) the Director may, within the limits imposed by the Act, extend the termination day until a day that the Director, having regard to the approved medical specialist's recommendation, considers will give the worker a reasonable opportunity to make an election under section 93K(4)(a) of the Act. (4) If the application is made in the circumstances described in section 93M(4)(b) of the Act, the Director cannot extend the termination day to a day that is more than 6 months after the day on which the Director gives the extension. (5) If the application is made in the circumstances described in section 93M(4)(c) of the Act - (a) when the application form is lodged - (i) if the worker has, in writing, requested an assessment of the worker's degree of permanent whole of person impairment, the Director has to be provided with a copy of the worker's request; and (ii) if the approved medical specialist has notified the worker, in writing, that more time is or was required to give the worker the documents required by section 146H of the Act than the time described in section 93O(1)(d) of the Act, the Director has to be provided with a copy of the notification; and (b) the Director may, within the limits imposed by the Act, extend the termination day until a day that the Director, having regard to the further time needed by the approved medical specialist, considers will give the worker a reasonable opportunity to make an election under section 93K(4)(a) of the Act. (6) If the application is made in the circumstances described in section 93M(4)(d)(i) or (ii) of the Act - (a) when the application form is lodged - (i) the Director has to be provided with a copy of the worker's request for an assessment of the worker's degree of permanent whole of person impairment; and (ii) if the approved medical specialist has notified the worker, in writing, that it would be impracticable to give the worker the documents required by section 146H of the Act at least 7 days before the termination day, the Director has to be provided with a copy of the notification; and (b) the Director may, within the limits imposed by the Act, extend the termination day until a day that the Director considers will give the worker a reasonable opportunity to make an election under section 93K(4)(a) of the Act. [Regulation 23 inserted in Gazette 28 Oct 2005 p. 4889-92.] 24. Expected time for approved medical specialist to give assessment documents An approved medical specialist can reasonably be expected to take 6 weeks, after a worker requests an assessment of the worker's degree of permanent whole of person impairment, to give the worker the documents that the approved medical specialist is required by section 146H of the Act to give the worker. [Regulation 24 inserted in Gazette 28 Oct 2005 p. 4892.] 25. Employer's obligation to notify worker The notice that an employer is required by section 93O(1) of the Act to give to a worker has to be given by sending the worker a document in the form of Form 36 in Appendix I. [Regulation 25 inserted in Gazette 28 Oct 2005 p. 4893.] Part 4 - Registered agents [Heading inserted in Gazette 28 Oct 2005 p. 4893.] Division 1 - Preliminary [Heading inserted in Gazette 28 Oct 2005 p. 4893.] 26. Terms used In this Part - applicant means an applicant for registration; code of conduct means the code of conduct set out in Appendix IV; employer, in relation to an applicant or registered agent, other than a person in a class of persons prescribed under regulation 27A(b) or (c), means the person or body - (a) by which the applicant or registered agent is employed or engaged; and (b) as an employee or officer of which the applicant proposes to act as a registered agent, or of which the registered agent acts as a registered agent; fit and proper person, in relation to an applicant or registered agent, means a person who satisfies WorkCover WA that he or she - (a) by reason of qualification or experience or both, has sufficient knowledge of the workers' compensation jurisdiction to represent a party effectively; and (b) is of good character; independent agent means a person in a class of persons prescribed under regulation 27A(c); registration means registration under this Part as a registered agent. [Regulation 26 inserted in Gazette 28 Oct 2005 p. 4893; amended in Gazette 9 Dec 2005 p. 5892.] 27. Prescribed organisations (section 277(1)(e)) The following organisations are prescribed for the purposes of section 277(1)(e) of the Act - (a) the Asbestos Diseases Advisory Service of Australia; (b) UnionsWA; (c) the Chamber of Commerce and Industry of Western Australia. [Regulation 27 inserted in Gazette 9 Dec 2005 p. 5892.] 27A. Prescribed classes of persons (section 277(1)(f)) The following classes of persons are prescribed for the purposes of section 277(1)(f) of the Act - (a) persons employed or engaged by a person or body that is engaged to provide claims management services to a self-insurer; (b) persons engaged by a self-insurer to provide claims management services to the self-insurer; (c) persons to whom section 277 of the Act does not otherwise apply and who act, or propose to act, as independent agents in the Conciliation Service or the Arbitration Service. [Regulation 27A inserted in Gazette 9 Dec 2005 p. 5892-3; amended in Gazette 18 Nov 2011 p. 4823.] Division 2 - Registration and renewal [Heading inserted in Gazette 28 Oct 2005 p. 4894.] 28. Application for registration (1) An application for registration must be made to WorkCover WA in a form approved by WorkCover WA. (2) Unless an application is made by a person in a class of persons prescribed under regulation 27A(b) or (c), it must include a nomination of the applicant signed by the applicant's employer. (2a) An application by an independent agent must be accompanied by - (a) a criminal record check in respect of the applicant issued not more than 3 months before the application is made; (b) if the criminal record check shows details of a conviction, a statement detailing the grounds on which the applicant believes that, having regard to the conduct required under the code of conduct, the conviction is of a kind that does not relate to whether or not the applicant is a fit and proper person to be registered; (c) a statement setting out the qualifications of the applicant, or any experience of the applicant, that demonstrates sufficient knowledge of the workers' compensation jurisdiction to enable the applicant to represent a party effectively; (d) a statutory declaration verifying the particulars contained in the application and accompanying material. (2b) An application by a person in a class of persons prescribed under regulation 27A(a) or (b) must be accompanied by - (a) a statement identifying the self-insurers to whom the agent, or the employer of the agent, is engaged to provide claims management services; and (b) a statutory declaration verifying the particulars contained in the statement. (3) The application must be accompanied by evidence satisfactory to WorkCover WA that - (a) there is, or upon registration under this Part will be, in force with respect to the applicant a policy of professional indemnity insurance for not less than $1 million for any one claim; or (b) within the meaning of subregulation (4), the applicant has sufficient material resources to provide professional indemnity. (4) A person has sufficient material resources to provide professional indemnity if - (a) the person is nominated by an employer who - (i) maintains professional indemnity insurance for not less than $1 million for any one claim; or (ii) holds legal or equitable estates or interests of not less than $1 million in real or personal property; or (b) the person holds legal or equitable estates or interests of not less than $1 million in real or personal property. (5) The applicant must provide WorkCover WA with any additional information or document that WorkCover WA may ask for. (6) In subregulation (2a)(a) - criminal record check means a document issued by the Western Australian Police Service, Australian Federal Police or another body or agency approved by WorkCover WA that sets out the criminal convictions of an individual for offences under the law of Western Australia, the Commonwealth, another State or a Territory. [Regulation 28 inserted in Gazette 28 Oct 2005 p. 4894-5; amended in Gazette 9 Dec 2005 p. 5893-4.] 29. Registration (1) WorkCover WA may refuse to register an applicant if - (a) the application is not duly made; or (b) in the case of an application by an independent agent, the applicant is not a fit and proper person to be a registered agent. (2) WorkCover WA cannot refuse an application unless it has - (a) given the applicant written notice of the intention to refuse the application, and of the grounds for the proposed refusal; and (b) allowed at least 21 days for the applicant to show cause why the application should not be refused. (3) In the case of a registered agent other than a person in a class of persons prescribed under regulation 27A(b) or (c), registration has effect to the extent that the person acts as a registered agent as an employee or officer of the employer that nominates the person in the application under regulation 28(2), and not otherwise. (4) In the case of a registered agent who is a person in a class of persons prescribed under regulation 27A(a) or (b), registration has effect to the extent that the person acts as a registered agent for - (a) a self-insurer identified in the agent's application under regulation 28(2b); or (b) a self-insurer identified in a statement - (i) provided to WorkCover WA after registration by the agent; (ii) verified by statutory declaration of the agent; and (iii) accepted by WorkCover WA. [Regulation 29 inserted in Gazette 28 Oct 2005 p. 4895; amended in Gazette 9 Dec 2005 p. 5894-5.] 30. Indemnity and other conditions of registration (1) It is a condition of registration that the professional indemnity insurance or material resources of the registered agent referred to in regulation 28(3) must be maintained during the period of registration. (2) It is a condition of registration that the registered agent must comply with the code of conduct. (3) In the case of a registered agent other than a person in a class of persons prescribed under regulation 27A(b) or (c), it is a condition of registration that the person will not act as a registered agent other than as an employee or officer of the employer who nominated the agent in the application for registration. (4) In the case of a registered agent who is a person in a class of persons prescribed under regulation 27A(a) or (b), it is a condition of registration that the person will not act as a registered agent other than for - (a) a self-insurer identified in the agent's application under regulation 28(2b); or (b) a self-insurer identified in a statement - (i) provided to WorkCover WA after registration by the agent; (ii) verified by statutory declaration of the agent; and (iii) accepted by WorkCover WA. [Regulation 30 inserted in Gazette 28 Oct 2005 p. 4895-6; amended in Gazette 9 Dec 2005 p. 5895.] 31. Duration of registration (1) Except as provided in subregulation (3), a registration has effect from the day it is granted and continues in force until the following 30 June. (2) An application for the renewal of registration may be made at any time before the registration expires and, except as provided in subregulation (3), any such renewal has effect for the period 1 July to 30 June. (3) If a registered agent is removed from the register under regulation 36, or has his or her registration suspended or cancelled under regulation 38 or 39, the registration or renewal has effect until that removal or suspension, as the case requires. [Regulation 31 inserted in Gazette 28 Oct 2005 p. 4896.] 32. Application for renewal of registration (1) An application for renewal of registration must be made in the same manner and form as an application for registration. (2) An application for renewal must be made not later than 28 days before the day on which the registration is due to expire. (3) WorkCover WA may shorten the period referred to in subregulation (2) and may do so either before or after the application is required to be made under that subregulation. (4) WorkCover WA may refuse to renew the registration if - (a) the application is not duly made; or (b) in the case of an application by an independent agent, the applicant is not a fit and proper person to be a registered agent. (5) WorkCover WA cannot refuse to renew the registration unless it has - (a) given the applicant written notice of the intention to refuse the application, and of the grounds for the proposed refusal; and (b) allowed at least 21 days for the applicant to show cause why the application should not be refused. [Regulation 32 inserted in Gazette 28 Oct 2005 p. 4896-7; amended in Gazette 9 Dec 2005 p. 5895-6.] 33. Certificate of registration (1) WorkCover WA must issue a person with a certificate of registration - (a) on the registration of the person; and (b) on the renewal of the person's registration. (2) The period for which the registration of the person has effect must be entered on the certificate. (3) In the absence of evidence to the contrary a certificate of registration is evidence that the person to whom the certificate is issued is registered for the period specified in the certificate. [Regulation 33 inserted in Gazette 28 Oct 2005 p. 4897.] 34. False or misleading information A person must not in relation to an application for registration or renewal of registration give information orally or in writing that the person knows to be - (a) false or misleading in a material particular; or (b) likely to deceive in a material way. Penalty: a fine of $1 000. [Regulation 34 inserted in Gazette 28 Oct 2005 p. 4897.] Division 3 - The register [Heading inserted in Gazette 28 Oct 2005 p. 4898.] 35. Register (1) WorkCover WA must keep a register in a manner and form determined by it. (2) WorkCover WA is to record in the register - (a) the name and address of each registered agent; (b) the name and address of the employer, if any, of the registered agent; (c) the date of the initial registration and each date of renewal of registration of each registered agent; and (d) such other particulars as WorkCover WA may determine. (3) WorkCover WA must allow any person - (a) to inspect the register; and (b) to take copies of, or extracts from, any part of it. (4) A person may, on application to WorkCover WA, obtain a certified copy of a part of, or entry in, the register. (5) WorkCover WA must make the amendments, additions and corrections to the register that are necessary to make the register an accurate record of the particulars in relation to all registered agents. [Regulation 35 inserted in Gazette 28 Oct 2005 p. 4898; amended in Gazette 9 Dec 2005 p. 5896.] 36. Removal from register (1) WorkCover WA may, on the written request of a registered agent and the return of the relevant certificate of registration, remove the name of the registered agent from the register. (2) WorkCover WA may remove the name of a registered agent from the register if the employer who nominated the registered agent under regulation 28(2) notifies WorkCover WA in writing that the employer has withdrawn the nomination. [Regulation 36 inserted in Gazette 28 Oct 2005 p. 4898-9.] Division 4 - Disciplinary powers [Heading inserted in Gazette 28 Oct 2005 p. 4899.] 37. Restriction on exercise of powers WorkCover WA cannot take disciplinary action under regulation 38 or 39 unless it has given the registered agent and the employer, if any, who nominated the registered agent under regulation 28(2) an opportunity to show cause why the action should not be taken. [Regulation 37 inserted in Gazette 28 Oct 2005 p. 4899; amended in Gazette 9 Dec 2005 p. 5896.] 38. Cancellation of registration WorkCover WA may cancel the registration of a registered agent if WorkCover WA is satisfied that the registered agent has ceased to be an employee or officer of the employer who nominated the registered agent under regulation 28(2). [Regulation 38 inserted in Gazette 28 Oct 2005 p. 4899.] 39. Taking disciplinary action (1) Proper causes for disciplinary action in respect of a registered agent are that the registered agent - (a) improperly obtained registration; (b) has contravened a condition of that person's registration; or (c) has done or omitted to do something, or engaged in conduct, that renders the person unfit to be registered. (2) WorkCover WA may, on receiving a written complaint about a registered agent, carry out any investigation necessary to decide whether there is proper cause for disciplinary action in respect of a registered agent. (3) If WorkCover WA is satisfied that proper cause exists for disciplinary action, WorkCover WA may - (a) reprimand or caution the registered agent; (b) attach a condition to the registration; (c) suspend the registration for a period not exceeding 12 months; or (d) cancel the registration. [Regulation 39 inserted in Gazette 28 Oct 2005 p. 4899-900.] 40. Return of certificate of registration (1) If WorkCover WA suspends or cancels a person's registration it must give directions in writing to the person as to the return to it of the certificate of registration. (2) A person given a direction under subregulation (1) must comply with the direction. Penalty: a fine of $1 000. [Regulation 40 inserted in Gazette 28 Oct 2005 p. 4900.] Division 5 - Review [Heading inserted in Gazette 28 Oct 2005 p. 4900.] 41. Review A person aggrieved by a decision of WorkCover WA to - (a) refuse an application for registration or for renewal of registration; or (b) suspend or cancel the person's registration, may apply to the State Administrative Tribunal for a review of that decision. [Regulation 41 inserted in Gazette 28 Oct 2005 p. 4900.] Division 6 - Miscellaneous [Heading inserted in Gazette 28 Oct 2005 p. 4901.] 42. Evidentiary matters In all courts and before all persons and bodies authorised to receive evidence, in the absence of evidence to the contrary - (a) a certificate purporting to be issued by WorkCover WA and stating - (i) that a person was or was not registered; (ii) that a person's registration was suspended or cancelled, on any day or days or during a period mentioned in the certificate is evidence of the matters so stated; and (b) a copy of, or extract from the register or any statement that purports to reproduce matters entered in the register and that is certified by WorkCover WA as a true copy, extract or statement, is evidence of the facts appearing in that copy, extract or statement. [Regulation 42 inserted in Gazette 28 Oct 2005 p. 4901.] [43. Deleted in Gazette 18 Nov 2011 p. 4823.] Part 5 - Injury management [Heading inserted in Gazette 28 Oct 2005 p. 4903.] 44. Vocational rehabilitation services The services listed in column 2 of the Table to this regulation and described in column 3 are services the provision of which, if they are for the purpose of enabling the worker to return to work, may be "vocational rehabilitation" as defined in section 5(1) of the Act. Table |column 1 |column 2 |column 3 | |item |service |description | |1 |support |activities to assist | | |counselling |the worker to adjust to| | | |the injury and to the | | | |worker's return to | | | |work; family | | | |counselling related to | | | |vocational | | | |rehabilitation; | | | |progress counselling | | | |related to the progress| | | |of, and problems with, | | | |the worker's return to | | | |work | |2 |vocational |activities focussed on | | |counselling |problems the worker has| | | |in selecting and | | | |preparing for | | | |vocational change | |3 |purchase of aids|advising and assisting | | |and appliances |the worker with the | | | |purchase of aids and | | | |appliances | |4 |case management |activities associated | | | |with the management of | | | |the worker's return to | | | |work, which may include| | | |liaising and | | | |negotiating with the | | | |parties, developing, | | | |coordinating and | | | |otherwise managing, and| | | |reviewing, the service | | | |delivery plan, and | | | |arranging for | | | |interpreter services | |5 |retraining |assisting a worker to | | |criteria |explore eligibility to | | |assistance |participate in a | | | |specialised retraining | | | |program and to prepare | | | |information to show | | | |that the retraining | | | |criteria are satisfied | |6 |specialised |services to assist a | | |retraining |worker undertake a | | |program |specialised retraining | | |assistance |program | |7 |training and |assisting to develop | | |education |the worker's skills and| | | |knowledge, which may | | | |include providing | | | |training courses or | | | |other aspects of injury| | | |management | |8 |workplace |activities involving | | |activities |analysis of work | | | |behaviour and analysis | | | |and design of job | | | |duties | |9 |placement |activities focussed on | | |activities |obtaining a new job for| | | |the worker, which may | | | |include assistance with| | | |the preparation of a | | | |resume and preparation | | | |for an interview and | | | |research and other | | | |assistance in finding | | | |jobs | |10 |assessments: | | |(a) |functional |activities associated | | |capacity |with assessing the | | | |worker's functional | | | |capacity, which may | | | |include preparing a | | | |report | |(b) |vocational |activities associated | | | |with assessing the | | | |worker's vocational and| | | |retraining options, | | | |which may include | | | |preparing a report | |(c) |ergonomic |activities associated | | | |with assessing how a | | | |particular work | | | |environment would | | | |affect the worker, | | | |which may include | | | |preparing a report | |(d) |job demands |activities associated | | | |with identifying and | | | |assessing the physical | | | |and cognitive demands | | | |of a job, which | | | |includes preparing a | | | |report | |(e) |workplace |activities associated | | | |with assessing the | | | |suitability of various | | | |workplace alternatives | | | |and other job options, | | | |which may include | | | |preparing a report | |(f) |aids and |activities associated | | |appliances |with developing | | | |recommendations for | | | |aids and appliances to | | | |assist the worker, | | | |which may include | | | |preparing a report | |11 |travel |travel that is | | | |associated with | | | |providing vocational | | | |rehabilitation | |12 |medical |discussion with | | | |specialists and other | | | |medical practitioners | | | |about vocational | | | |rehabilitation, which | | | |may include preparing a| | | |report | |13 |general reports |status reports relating| | | |to vocational | | | |rehabilitation | [Regulation 44 inserted in Gazette 28 Oct 2005 p. 4903-5.] 44A. Counselling psychology (1) In this regulation - counselling psychologist means a psychologist who has completed a 4 year psychology degree, a 2 year Master's degree in counselling psychology and 2 years of weekly supervision of full-time practice after completion of the Master's degree. (2) Where counselling psychology is approved under section 5(1) of the Act as an "approved treatment" for workers suffering disabilities that are compensable under the Act, that treatment can only be provided by a counselling psychologist. [Regulation 44A inserted in Gazette 15 Dec 2006 p. 5637.] 44B. Exercise physiology (1) In this regulation - exercise physiologist means an individual with current accreditation as an exercise physiologist by the Australian Association for Exercise and Sports Science. (2) Where exercise physiology is approved under section 5(1) of the Act as an "approved treatment" for workers suffering disabilities that are compensable under the Act, that treatment can only be provided by an exercise physiologist. [Regulation 44B inserted in Gazette 17 Dec 2008 p. 5333-4.] 45. Insurer to advise of injury management obligations (1) Subregulation (2) specifies the action that section 155D(1) of the Act requires an insurer to take to make an employer aware of the employer's obligations under section 155B and section 155C(1) and (3) of the Act. (2) Whenever the insurer issues to an employer, or renews, a policy of insurance against the employer's liability to pay compensation under the Act, the insurer has to give the employer a written notice informing the employer of the things described in subregulation (3). (3) The notice has to inform the employer that - (a) section 155A(1) of the Act authorises WorkCover WA to issue a code of practice (injury management) and WorkCover WA will, on request, provide a copy of a code it issues; (b) section 155B of the Act requires the employer to establish and implement an injury management system in accordance with the code; and (c) section 155C of the Act requires the employer to establish and implement a return to work program for a worker in accordance with the code in circumstances described in that section. [Regulation 45 inserted in Gazette 28 Oct 2005 p. 4905-6.] [46. Deleted in Gazette 18 Nov 2011 p. 4823.] Part 6 - Specialised retraining programs [Heading inserted in Gazette 28 Oct 2005 p. 4907.] 47. Recording agreement (1) If - (a) the worker and the employer agree that the worker's degree of permanent whole of person impairment is at least 10% but less than 15%; and (b) the worker, in writing, requests the Director to record the agreement, the Director is required to record the agreement in a register kept for the purpose. (2) If - (a) the worker and the employer agree that the worker satisfies all of the retraining criteria; and (b) the worker, in writing, requests the Director to record the agreement, the Director is required to record the agreement in a register kept for the purpose. (3) A request under subregulation (1)(b) or (2)(b) for the Director to record an agreement has to include - (a) the worker's name and any other details necessary to identify the worker; (b) details sufficient to enable the worker to be contacted; (c) the worker's date of birth; (d) the date on which the injury occurred and a description of the injury; (e) if a claim for compensation under the Act for the injury has been made, the date on which the worker's claim was made and sufficient other details to identify the claim (including any claim number that may have been given to the claim); (f) the employer's name and any other details necessary to identify the employer; (g) details sufficient to enable the employer to be contacted; and (h) the name of the insurer, if any. (4) The Director's record in the register is to be in the form of - (a) if subregulation (1) requires the record, Form 37 in Appendix I; (b) if subregulation (2) requires the record, Form 38 in Appendix I, and the Director is required to give a copy of the record to each of the worker and the employer. [Regulation 47 inserted in Gazette 28 Oct 2005 p. 4907-8.] 48. Extending final day (1) A worker may apply for the Director to extend the final day under section 158B of the Act. (2) The application is made by - (a) lodging with the Director a completed application form in the form of Form 39 in Appendix I; and (b) providing to the Director, with the application form, particulars about - (i) the action taken by the worker to obtain from the employer by the final day any agreement that the worker was unable to obtain as to - (I) the worker's degree of permanent whole of person impairment; or (II) whether the worker satisfies all of the retraining criteria; (ii) the worker's having, at least 8 weeks before the final day, requested an approved medical specialist to assess the worker's degree of permanent whole of person impairment; and (iii) the action taken by the worker towards applying under section 158C or 158D of the Act to have a matter in dispute determined by an arbitrator. (3) The Director may, within the limits imposed by the Act, extend the final day until a day that the Director considers will give the worker a reasonable opportunity to take the action referred to in section 158B(1) of the Act. [Regulation 48 inserted in Gazette 28 Oct 2005 p. 4908-9.] 49. Request for WorkCover to direct payment (1) A person seeking that, under section 158F of the Act, WorkCover WA direct an employer or an insurer to make a payment may, in accordance with this regulation, request WorkCover WA to give the direction. (2) The request has to be made to WorkCover WA in writing, giving - (a) the date on which the request is made; (b) the worker's name and any other details necessary to identify the worker; (c) details sufficient to enable the worker to be contacted; (d) reasons justifying the giving of the direction; and (e) the date, if any, by which the payment needs to be made. (3) If the payment is to satisfy a debt incurred or to recoup the cost of any payment that has been made, the request has to be accompanied by copies of relevant invoices or other sufficient evidence of the debt or cost, showing details of each item charged and the rate at which it was charged, if applicable. [Regulation 49 inserted in Gazette 28 Oct 2005 p. 4909-10.] Part 7 - Infringement notices and modified penalties [Heading inserted in Gazette 28 Oct 2005 p. 4910.] 50. Prescribed offences The offences described in Appendix V are the offences for which an infringement notice may be given under section 175G(1) of the Act. [Regulation 50 inserted in Gazette 28 Oct 2005 p. 4910.] 51. Prescribed modified penalties A penalty specified in Appendix V is the modified penalty for the corresponding offence in Appendix V for the purposes of section 175H(2)(b) of the Act. [Regulation 51 inserted in Gazette 28 Oct 2005 p. 4910.] 52. Prescribed form of infringement notice The form of an infringement notice is set out in Appendix I Form 40 for the purposes of section 175H(1) of the Act. [Regulation 52 inserted in Gazette 28 Oct 2005 p. 4910.] 53. Prescribed form of withdrawal of notice The form of a notice to withdraw an infringement notice is set out in Appendix I Form 41 for the purposes of section 175J(1) of the Act. [Regulation 53 inserted in Gazette 28 Oct 2005 p. 4911.] Appendix I Form 1 [r. 4(1)] Workers' Compensation and Injury Management Act 1981 ELECTION FOR SCHEDULE 2 INJURIES UNDER PART III DIVISION 2 (Section 24B) I, (name in full block letters) of (address) suffered compensable personal injury by accident in the employment of (name of employer) on the ....................................... day of ............................................ 20 The injury/injuries suffered by me was/were: (state nature of injury and percentage loss of use or loss of efficient use of a part or faculty of the body) *Before that injury was suffered I had previously suffered compensable personal injury by accident to that part or faculty of the body resulting in ............... % loss of use of that part or faculty. I elect to receive compensation under Part III Division 2 of the Workers' Compensation and Injury Management Act 1981 which I anticipate should be the sum of $....................... representing ............. % loss of item .................................. being (state the part or faculty of the body affected) In making this election and upon an agreement being registered under Division 7 of Part 3 of the Act or an award being made by a dispute resolution authority, I acknowledge that after registration or the making of the award: (1) I shall have no further entitlement to compensation under the Act for weekly payments arising out of that injury; (2) I shall have no further entitlement in respect of that injury subsequent to the date of this election, to payment of expenses under the Workers' Compensation and Injury Management Act 1981 Schedule 1 clauses 9, 17, 18, 18A and 19 (that is, in general terms, medical or surgical, dental, physiotherapy or chiropractic advice or treatment, first aid and ambulance expenses, medical requisites, charges for attendance and treatment by way of injury management, charges for hospital treatment and maintenance, cost of artificial aids and travelling expenses); (3) I shall have no entitlement to further moneys upon any increase to the prescribed amount for this percentage loss of the part or faculty of the body the subject of this election. Dated the day of 20 . .......................................... (Signature) in the presence of: ........................................... (Signature and full names and address of witness) *Delete if not applicable. [Form 1 amended in Gazette 26 Feb 1991 p. 939; 8 Mar 1991 p. 1076; 18 Feb 1994 p. 662; 17 Nov 2000 p. 6319; 21 Jan 2005 p. 276; 28 Oct 2005 p. 4912-13.] Form 1A [r. 4(2)] Workers' Compensation and Injury Management Act 1981 ELECTION FOR SCHEDULE 2 INJURIES UNDER PART III DIVISION 2A (Section 31H) |Surname Mr/Mrs/Miss/Ms | | | |Other Names | | | |Address | | | | | |......................................................| |................Postcode | |Phone | |No.(H).........................(W)....................| |...(Mb) | |Occupation | |(e.g. boiler maker, underground miner) | |Main tasks or duties performed | |(e.g. welding, drilling) | |Employer at date of injury | |Address of employer | | | |......................................................| |.................Postcode | | | | | | | | | WORKER'S DECLARATION Date of injury/injuries Type of injury/injuries Degree of permanent impairment * Before that impairment was suffered I had previously suffered a permanent impairment from a compensable personal injury by accident to that part or faculty of the body resulting in ................ degree of permanent impairment of that part or faculty. I elect to receive compensation under the Workers' Compensation and Injury Management Act 1981 Part III Division 2A which I anticipate should be the sum of $ ........................................ representing ............. % of item ............................. being ......................................................................... . (state the part or faculty of the body affected) In making this election and upon an agreement being registered under Part III Division 7 of the Act or an award being made by a dispute resolution authority, I acknowledge that after registration or the making of the award: (1) I shall have no further entitlement to compensation under the Act for weekly payments arising out of that injury. (2) I shall have no further entitlement in respect of that injury subsequent to the date of this election, to payment of expenses under the Workers' Compensation and Injury Management Act 1981 Schedule 1 clauses 9, 17, 18, 18A and 19 (that is, in general terms, medical or surgical, dental, physiotherapy or chiropractic advice or treatment, first aid and ambulance expenses, medical requisites, charges for attendance and treatment by way of injury management, charges for hospital treatment and maintenance, cost of artificial aids and travelling expenses). (3) I shall have no entitlement to further moneys upon any increase to the prescribed amount for this degree of permanent impairment the subject of this election. Dated the ....................day of ....................................20..... . .......................................... (Signature of worker) in the presence of: (Signature and full names and address of witness) ______________________________________________________________ *Delete if not applicable. [Form 1A inserted in Gazette 28 Oct 2005 p. 4913-14.] Form 2 [r. 5] Workers' Compensation and Injury Management Act 1981 MEDICAL PANEL (Sections 36 and 38) Particulars of Claimant Surname Christian Names Address Date of Birth __________ DETERMINATION 1. Is, or was, the worker suffering from pneumoconiosis, mesothelioma or lung cancer? 2. If so, is, or was, the worker thereby less able to earn full wages? 3. To what extent if any does, or did - (i) pneumoconiosis; (ii) mesothelioma; (iii) lung cancer; (iv) diffuse pleural fibrosis, adversely affect the worker's ability to undertake physical effort? 4. What other, if any, disease or physical condition is, or was, contributing to the worker's being less able to earn full wages, or death and to what extent? 5. Is, or was, the worker fit for work? If so, at what level - light, moderate, or heavy? Signed: ................................................ (Chairman) ................................................ (Member) ................................................ (Member) Date ........................................ Attendance of Medical Practitioner. I hereby certify that of a Medical Practitioner, attended the examination of the above claimant. ................................................ (Chairman) [Form 2 amended in Gazette 8 Mar 1991 p. 1076; 24 Dec 1993 p. 6845-6; 17 Nov 2000 p. 6320; 21 Jan 2005 p. 276; 18 Nov 2011 p. 4823.] [Form 2A deleted in Gazette 15 Oct 1999 p. 4900.] Form 2B [r. 6AA] Workers' Compensation and Injury Management Act 1981 (Section 178(1)(b)) Workers' Compensation Claim Form Insurer please complete Date form received from employer: ASCO (office use only): Insurer name: Claim number: ANZSIC code: Policy number: WorkCover number: Has employer contacted medical practitioner? Estimated time off work: ? less than one day ? 1-4 work days (inclusive) ? 5-9 work days (inclusive) ? 10-20 work days (inclusive) ? more than 20 work days ? fatality Employer please complete Name of policy holder/employer: Trading as (if different to above): Address: Postcode: Contact person: Name: Phone number: Email: Address of injured worker's usual workplace or base: Postcode: Major activity of workplace: (e.g. sheep farming, plumbing) Date employer received the completed claim form from the injured worker: Date employer received first medical certificate from the injured worker: Date employer sent the claim form and medical certificate/s to insurer: Worker please complete Surname: Other names: Date of birth: ? Male ? Female Preferred language (if not English): Address Postcode Email: Daytime contact phone number: Occupation (e.g. first class welder): Main tasks/duties performed (e.g. welding of high pressure steam pipes): At the time of the injury I was working as a: ? direct employee ? working director ? contractor ? employee of a contractor ? subcontractor ? visa worker ? other At the time of the injury I was engaged as: ? full-time ? part-time ? permanent ? temporary ? casual Worker please complete - Other employment Do you have any other job? If yes, please give details: Employer name: Contact phone number: Hours of work per week: Worker please complete - Occurrence details Day of occurrence: Date of occurrence: Time of occurrence: At what address did the occurrence happen? Did you have to stop working? If so when? Date: Time: Were you: ? working - at your normal workplace ? working - away from normal workplace ? working - road traffic accident ? on work break - at normal workplace ? on work break - away from normal workplace ? other duty status ? commuting/journey Describe the occurrence. Include: (i) What action was involved (i.e. fall, struck by object,): [Mechanism] (ii) What object/machine/substance was involved (i.e. fumes, door frame): [Agency] (iii) The most serious injury or disease caused (i.e. fracture, burn, abrasion): [Nature] (iv) The bodily location of the injury or disease (i.e. upper arm, eye): [Bodily location] Worker please complete - Occurrence report - Describe how it happened Where did the occurrence happen? (i.e. store room, machinery shop): What were you doing at the time of the occurrence? What were the normal working hours for that day? Starting time: Finish time: When did you first report the occurrence? Date: Time: Who did you report the occurrence to? Name: Position: Phone number: If you didn't report the occurrence immediately, please state the reason if any: Please provide the name and daytime contact phone number of witnesses of the occurrence: Name: Phone number: Name: Phone number: Worker please complete - Medical help/history - This occurrence When did you first seek medical attention? Date: Time: If not immediately, please state the reason: Was the part of the body affected by this occurrence healthy before this occurrence? If not, please give details: Is the present injury completely related to this occurrence? If not, please give details: Please give details of any similar injury prior to this occurrence: Name and contact details of your usual medical practitioner and any health provider who has treated you for a similar injury: Name: Address: Phone number: Worker please complete - Other / Previous claims Are you claiming compensation from any other source? If yes, from whom? Have you had any similar or related workers' compensation claims? If yes, please give details: Name of employer: Address of employer: Name of insurer (if known): Type of injury or disease: Worker's declaration - worker please complete I solemnly and sincerely declare that each and every answer above and the particulars contained herein or annexed hereto relating to myself and the occurrence are true both in substance and in fact to the best of my knowledge and belief. I take notice that, under the provisions of section 59(2) of the Workers' Compensation and Injury Management Act 1981, I am required to notify my employer in writing within 7 days if I commence work with another employer after making a claim, or while receiving weekly payments of workers' compensation. Dated this day of: Year: Signature of worker Signature of witness Consent authority 1 (to be signed at the option of the worker) I authorise any doctor who treats me (whether named in this certificate or not) to discuss my medical condition, in relation to my claim for workers' compensation and return to work options, with my employer and with their insurer. Signed: Date: Print your name: Witness signature: Witness print name: Consent authority 2 (to be signed at the option of the worker) I consent to my employer's insurer and its appointed service providers collecting personal information, inclusive of sensitive information such as medical information about me and using it for the purpose of assessing and managing my workers' compensation claim, including determining liability and whether my claim is true. This consent extends to my employer's insurer disclosing my personal information, inclusive of sensitive information, to other insurers, medical practitioners, rehabilitation providers, investigators, legal practitioners and other experts or consultants for the purpose of assessing and managing my claim. My personal information, inclusive of sensitive information, may also be disclosed as required or permitted by law. I also consent to my employer's insurer disclosing my personal details to WorkCover WA which is authorised to use this information to fulfil its functions and obligations under the Workers' Compensation and Injury Management Act 1981. I have read all the information on this form regarding the consent authority and I consent to the Insurer dealing with my personal information in the manner described. Signed: Date: Print your name: Witness signature: Witness print name: IMPORTANT: FAILURE TO PROVIDE YOUR SIGNATURE ON EITHER THE DECLARATION OR THE CONSENT AUTHORITIES MAY DELAY A DECISION BY THE INSURER ON YOUR CLAIM. [Form 2B inserted in Gazette 10 Sep 2010 p. 4352-7; amended in Gazette 18 Nov 2011 p. 4824.] Form 2C [regs 4(1), 6AA] Workers' Compensation and Injury Management Act 1981 (Sections 24B, 178(1)(b)) WORKER'S CLAIM AND ELECTION FOR LUMP SUM COMPENSATION FOR NOISE INDUCED HEARING LOSS WORKER'S DETAILS - (Worker to complete) |Surname Mr/Mrs/Miss/Ms | |Date of | |Age| |Sex| | | |Birth | | | | | |Other Names | |/ / | | | |M/F| | | | | | | | | | | | | | | | | |Address | | | | | | | | | | | | | | | | | | | | | | | |........................ | | | | | | | |Postcode | | | | | | | | | | | | | | | |Phone No. (H) | | | | | | | |.................... (W) | | | | | | | | | | | | | | | |Occupation | | | | | | | |(e.g. boiler maker, | | | | | | | |underground miner) | | | | | | | | | | | | | | | |Main tasks or duties | | | | | | | |performed | | | | | | | |(e.g. welding, drilling) | | | | | | | | | | | | | |If you have difficulty| | | |understanding English | | | |what is your preferred| | | |language? | | | | | | | |TYPE 32 | | | |AGENCY 991 | | | |ICD 250 | | | |LOCN 130 | | | |______________________| | | |________ | | | |office use only | | | |ASCO | ELECTION FOR SCHEDULE 2 INJURY - item 6 |NIHL FILE No. ...................... (Office Use Only)| | | |Date of compensable test ....../....../...... | |Compensable noise induced hearing loss ...........% | |(of item 6) Entitlement $ ............... | |Employer at time of test | |......................................................| |............................................. | |Address ...... Post Code ...................... | |Previous settlement date ....../....../...... | |PLH | |......................................................| |.......... | WORKER'S DECLARATION |I elect to accept under Part III Division 2 of the | |Workers' Compensation and Injury Management Act 1981 | |the sum of $ ......... representing ..........% of | |loss of Schedule 2 item 6 of the Act, being loss of | |hearing. In making this election I declare that I | |have not received nor am I eligible to receive | |compensation in respect of the noise induced hearing | |loss under any law of the Commonwealth, another State | |or Territory of the Commonwealth, or country other | |than Australia. In making this election and upon an | |agreement being registered by the Director, I | |acknowledge that after registration or making an | |award: | |1. I shall have no further entitlement to compensation| |under the Act for the percentage loss of hearing which| |is the subject of this election; | |2. I shall have no entitlement to further monies upon | |any increase to the prescribed amount for the | |percentage loss of hearing which is the subject of | |this election. | |DATED the .................... day of .............. | |20........ | |(Signature of worker) | |in the presence of : | | | |(Signature and full name and address of witness) | | | |WorkCover No. | | |EMPLOYER DETAILS - (Employer to | |.......... | | |complete) | | | | | | | | |Trading name of employer | |Local Gov. | |(e.g. Browns Welding; | | | |E.J. Drilling Service) | | | | | | | | | |Insurance Co. | | | | | | | | | |Address of worker's usual | | | |workplace or base | | | | | |Policy No. | |Name of Policy Holder | |Claim No: | |__________________________________| |Insurer/self | |____________ | |insurer to | |Address | |complete | |Suburb/Town Post Code | | | | | | | | | | | | | |Insurer/self | | | |insurer's date | | | |stamp | | | |_________________| | | |_____ | | | | | |Major activity or workplace | | | |(e.g. metal fabrication; | | | |gold mining, engineering.) | | | | | |office use only | | | |ANZSIC | WORKER'S EMPLOYMENT HISTORY FROM MARCH 1, 1991 To be completed by WorkCover WA: Name of worker ................................................ File # Name of insurer .................. Period of insurance .................. Policy No. Name of insurer .................. Period of insurance .................. Policy No. Name of insurer .................. Period of insurance .................. Policy No. Name of insurer .................. Period of insurance .................. Policy No. Employer at March 1, 1991: (Name) Address (Postcode) Telephone Number (.........) .............................. Type of work engaged in ............................................. Prescribed ( Yes ( No Baseline Test Date......./......../........ PLH ( ( . ( ( / NO BASELINE TEST (if worker has had a Full Audiological Baseline Test use the date please circle if applicable and PLH of the full audiological test) Subsequent Test Date......./......../........ PLH ( ( . ( ( Subsequent Test Date......./......../........ PLH ( ( . ( ( Subsequent Test Date......./......../........ PLH ( ( . ( ( Subsequent Test Date......./......../........ PLH ( ( . ( ( Subsequent Test Date......./......../........ PLH ( ( . ( ( Subsequent Test Date......./......../........ PLH ( ( . ( ( Subsequent Test Date......./......../........ PLH ( ( . ( ( Subsequent Full Audio Test Date......./......../........ PLH ( ( . ( ( Otorhinolarynigological assessment Date......./......../........ NIHLPLH ( ( . ( ( Number of years with this employer since the baseline test/March 1, 1991 ( ( Termination Date......./......../........ Subsequent test at termination Date......./......../........ PLH ( ( . ( ( NIHL Claims Officer check: Date......./......../........ Signature NIHL Manager check: Date......./......../........ Signature [Form 2C inserted in Gazette 25 Aug 1995 p. 3885-7; amended in Gazette 17 Nov 2000 p. 6320; 21 Jan 2005 p. 276; 28 Oct 2005 p. 4915- 16; 18 Nov 2011 p. 4824.] Form 2CA [regs 4(2), 6AA] Workers' Compensation and Injury Management Act 1981 (Sections 31H, 178(1)(b)) WORKER'S CLAIM AND ELECTION FOR LUMP SUM COMPENSATION FOR NOISE INDUCED HEARING LOSS WORKER'S DETAILS - (Worker to complete) |Surname Mr/Mrs/Miss/Ms | |Date of | |Age| |Sex | | | |Birth | | | |M/F | |Other Names | |/ / | | | | | | | | | | | | | |Address | | | | | | | | | | | | | | | | | | | | | | | |Postcode | | | | | | | |Phone No. (H) | | | | | | | |(W) | | | | | | | |Occupation | | | | | | | |(e.g. boiler maker, | | | | | | | |underground miner) | | | | | | | |Main tasks or duties | | | | | | | |performed | | | | | | | | | | | | | | | |(e.g. welding, drilling) | | | | | | | | | | | | | |If you have difficulty | | | |understanding English | | | |what is your preferred | | | |language? | | | | | | | |TYPE 32 | | | |AGENCY 991 | | | |ICD 250 | | | |LOCN 130 | | | |_______________________| | | |___ | | | |office use only | | | |ASCO | ELECTION FOR SCHEDULE 2 INJURY - item 44 |NIHL FILE No. ...................... (Office Use | |Only) | |Date of compensable test ....../....../...... | |Compensable noise induced hearing loss ........% (of | |item 44) Entitlement $ ........... | |Employer at time of test | |Address | |................................................... | |Post Code | |Previous settlement date ....../....../......PLH | WORKER'S DECLARATION |I elect to accept under the Workers' Compensation and| |Injury Management Act 1981 Part III Division 2A the | |sum of $ ......... representing ..........% of loss | |of Schedule 2 item 44, being loss of hearing. In | |making this election I declare that I have not | |received nor am I eligible to receive compensation in| |respect of the noise induced hearing loss under any | |law of the Commonwealth, another State or Territory | |of the Commonwealth, or country other than Australia.| |In making this election and upon an agreement being | |registered by the Director, I acknowledge that after | |registration or making an award: | |1. I shall have no further entitlement to | |compensation under the Act for the percentage loss of| |hearing which is the subject of this election; | |2. I shall have no entitlement to further monies upon| |any increase to the prescribed amount for the | |percentage loss of hearing which is the subject of | |this election. | |DATED the .................... day of .............. | |20........ | |.....................................................| |... | |(Signature of worker) | |in the presence of : | |.....................................................| |.....................................................| |............................ | |.....................................................| |.....................................................| |............................ | |(Signature and full name and address of witness) | | | |WorkCover No. | | |EMPLOYER DETAILS - (Employer to | |...... | | |complete) | | | | | | | | |Trading name of employer | |Local Gov. | |(e.g. Browns Welding; | | | |E.J. Drilling Service) | | | | | | | | | |Insurance Co. | | | | | | | | | |Address of worker's usual | |Policy No. | |workplace or base | | | | | | | |Name of Policy Holder | |Claim No: | |_________________________________| |Insurer/self | |_____ | |insurer to | |Address | |complete | |Suburb/Town Post Code | | | | | | | | | | | | | |Insurer/self-insu| | | |rer's date stamp | | | |_________________| | | | | |Major activity or workplace | | | |(e.g. metal fabrication, gold | | | |mining, engineering) | | | | | |office use only | | | |ANZSIC | WORKER'S EMPLOYMENT HISTORY FROM 1 MARCH 1991 To be completed by WorkCover WA: Name of worker ................................................. File No. Name of insurer ...................... Period of insurance .................. Policy No. Name of insurer ...................... Period of insurance .................. Policy No. Name of insurer ...................... Period of insurance .................. Policy No. Name of insurer ...................... Period of insurance .................. Policy No. Employer at 1 March 1991 . (Name) Address (Postcode) Telephone Number (.........) .............................. Type of work engaged in ............................................. Prescribed ( Yes ( No Baseline Test Date......./......../........ PLH ( ( . ( ( / NO BASELINE TEST (if worker has had a Full Audiological Baseline Test (please circle if applicable) use the date and PLH of the full audiological test) Subsequent Test Date....../......./....... PLH ( ( . ( ( Subsequent Test Date....../......./....... PLH ( ( . ( ( Subsequent Test Date....../......./....... PLH ( ( . ( ( Subsequent Test Date....../......./....... PLH ( ( . ( ( Subsequent Test Date....../......./....... PLH ( ( . ( ( Subsequent Test Date....../......./....... PLH ( ( . ( ( Subsequent Test Date....../......./....... PLH ( ( . ( ( Subsequent Full Audio Test Date....../......./....... PLH ( ( . ( ( Otorhinolaryngological assessment Date....../......./....... NIHLPLH ( ( . ( ( Number of years with this employer since the baseline test/1 March 1991 ( ( Termination Date......./......../........ Subsequent test at termination Date......./......../........ PLH ( ( . ( ( NIHL Claims Officer check Date......./......../........ Signature ................................... NIHL Manager check Date......./......../........ Signature .................................. [Form 2CA inserted in Gazette 28 Oct 2005 p. 4916-19.] Form 2D [r. 6AA] Workers' Compensation and Injury Management Act 1981 WORKERS' COMPENSATION CLAIM FORM FOR DEPENDANTS OF DECEASED WORKERS If insufficient space attach relevant details. If you can't fill in this form yourself you may ask someone to help you. If the deceased had no dependants this form can be used to claim for statutory allowances only (e.g. funeral expenses). Please complete all questions except for the details requested on dependants (see below). Applicant's Details |Full Name of |Surname | |Other Names | |Applicant | | | | | | | | | | |Occupation | |Relationship to | | | | |deceased worker | | | | | | | | | |i.e. Executor, | | | | |spouse, de facto | | | | |partner, son, | | | | |daughter | |Residential | | |Address | | | |Postcode |Telephone No. | Deceased Worker's Details |Full Name of |Surname | |Other Names | |deceased | | | | |worker | | | | | | | | | | | | | | |Sex | |Mal| |Femal| |Date of | / | | | |e | |e | |Birth |/ | |Worker's | | |Occupation | | |Period of | | |Employment | | |Residential | | |Address | | |immediately | | |prior to | | |death | | Employer's Details |Full Name of | | |Employer, | | |including | | |trading name | | | | | |Address of | | |worker's | | |usual |Postcode | |workplace or |Telephone No. | |base | | |Major | | |activity of | | |workplace | | |(e.g. | | |footwear | | |manufacturing| | |, | | |sheep farming| | |) | | Deceased Worker's Dependant/s Details Do not complete the following question if you are claiming for statutory allowances only. Give full details of deceased worker's dependants as at the date of death: |Name of |Date |Residen|Occupa|Relationsh|Dependenc| |Dependant|of |tial |tion |ip to |y | | |Birth|Address| |deceased |Wholly | | | | | |worker |Part | | | | | | |( Tick | | | | | | |Box | | | | | | |( ( | | | | | | |( ( | | | | | | |( ( | Details of Fatality |Was the death| |Yes| |No | |the result of| | | | | |a | | | | | |work-related | | |injury and/or| | |disease? | | |What was the | | |cause of | | |death? | | | | | | | | | | | |What were the| | |main | | |tasks/duties | | |of the | | |deceased's | | |employment | | |when he/she | | |suffered the | | |injury and/or| | |contracted | | |the disease? | | | | | | | | | | | | | | | | | | | | |In the case |Day of the| |Time | |Date | |of personal |week | | | | | |injury, when | | | | | | |did it occur?| | | | | | | | | | | | / | | | | | | |/ | | | |Date of death if|Date | / | | | | |different. | |/ | | | | |Where did the| | |injury occur?| | |(e.g. | | |Workshop | | |floor, Hay | | |Street, | | |Cloverdale) | | | | | | | | |In the case |Date | / |Date |Dat| | |of a disease,| |/ |of |e |/ | |what was the | | |diagno| |/ | |date of | | |sis | | | |death? | | | | | | | | | | | | | | | | | | | | | | | | | | | |If known, |Date | / |Don't | | | |when was the | |/ |know | | | |deceased | | | | | | |first | | | | | | |incapacitated| | | | | | |by the | | | | | | |disease? | | | | | | | | | | | | | | | | | | | | | | | |Prior to this application, have any workers' | |compensation payments been received or applied for| |in respect of the deceased (i.e. weekly payments, | |medical expenses, lump sums). | |Declaration | |I, the undersigned, do hereby warrant the truth of| |the foregoing statements. I hereby authorise any | |medical practitioner to disclose to the deceased | |worker's employer or his/her insurer and WorkCover| |WA any information regarding the deceased worker's| |medical history. | | | |Signatur| |Date | / | | |e | | |/ | | | | | | | | |Signatur| |Date | / | | |e | | |/ | | | | |INSURER/SELF-INSURER DETAILS | |Insurer/self-insurer to complete then detach and | |forward the duplicate of this notice to WorkCover | |WA, 2 Bedbrook Place, Shenton Park, WA 6008: | |Name of | |Date stamp of | |insurer/self-| |insurer/self-insurer | |insurer: | | | | | | | |Policy | | | |number: | | | |Claim number:| | | | | | | |WCN: | | | | | | | |Occurrence | | | |Details | | | |Mechanism: | | | |Agency: | | | |Nature: | | | |Body Locn: | | | | | | | [Form 2D inserted in Gazette 15 Oct 1999 p. 4901-2; amended in Gazette 17 Nov 2000 p. 6320; 30 Jun 2003 p. 2637; 21 Jan 2005 p. 276.] Form 3 [r. 6A, 7(1)] Workers' Compensation and Injury Management Act 1981 (Sections 57A(1)(b), 57B(1)(b) and 61(1)) FIRST MEDICAL CERTIFICATE 1. Worker's Details First name(s): ......................................................... Surname: Address: Telephone: ................................... Date of birth: ......./......../........ Occupation: ( I have provided a WorkCover WA Injury Management brochure to the worker. 2. Employer Details Name & address of worker's employer: 3. Consent Authority (to be signed at the option of the worker) I authorise any doctor who treats me (whether named in this certificate or not) to discuss my medical condition, in relation to my claim for workers' compensation and return to work options, with my employer and with their insurer. Worker's Signature .......................................... Date ............................. |IMPORTANT: FAILURE TO PROVIDE YOUR SIGNATURE ON THE | |AUTHORITY ABOVE MAY DELAY A DECISION BY YOUR EMPLOYER | |ON YOUR CLAIM. | AFFECTED AREA |4. Details from Worker Date of |[pic] | |injury by accident or approximate date | | |of onset of condition: | | |Workplace location where incident | | |occurred: | | |Worker's description of the injury: | | | | | |Worker's description of how it | | |occurred: | | | | | |5. Medical Assessment | | |Clinical findings / diagnosis (include | | |possible complications, effect of prior| | |injury or medical condition): | | |.......................................| | |.......................................| | |....................... | | |.......................................| | |.......................................| | |....................... | | |.......................................| | |.......................................| | |....................... | | |.......................................| | |.......................................| | |....................... | | |In my opinion the above diagnosis does | | |( / does not ( correlate with the | | |injury described to me by the worker. | | INJURY MANAGEMENT 6. Fitness for Work It is my opinion that as from the date of this certificate the worker is: FIT |( Fit to return to pre-injury|( First and Final | |duties, no further treatment |certificate | |required |[See reg. 7 and | | |s. 61(1) of the Act] | ( Fit to return to pre-injury duties, but requires further treatment ( Fit for restricted return to work from .............................................. to ( restricted hours (please specify): ( restricted days (please specify): ( restricted duties. ( Work restrictions: | ( No lifting |Other restrictions: | |anything heavier than | | |.......... kg. | | |( Avoid repetitive | | |bending / lifting. | | |( Avoid repetitive use of| | |body part. | | |( Avoid prolonged | | |standing / walking / | | |sitting. | | |( Keep injured area clean| | |and dry. | | UNFIT ( Totally unfit for work for .................... days from ..................... to ....................... (inclusive). 7. Medical Management ( Medication: ( Approved allied health treatments (specify type and include number of sessions recommended) ( Imaging ( Referred to hospital/specialist (name) Other treatment: Next appointment (unless "First & Final Certificate") Date ........................ Time If the worker is reviewed within 14 days, the worker cannot be required, under section 64 or 65 of the Act, to submit to a medical examination by a medical practitioner provided by the employer, on a day chosen by the employer that is within one month of the date of this certificate. 8. Medical Practitioner / Employer Contact ( I have made contact with the employer and discussed alternative work options. ( The worker will be off work for more than 3 working days and/or is unable to return to normal duties. Employer please fax your contact details as I will contact you to discuss return to work options. ( The worker is able to return to normal duties. Contact with employer not necessary at this stage. 9. Medical Practitioner's Details Name ....................................................... Registration No. Address Telephone ................................................. Signature Fax .......................................................... Time & Date of examination For workers' compensation information or assistance contact WorkCover WA's Infoline: 1300 794 744 [Form 3 inserted in Gazette 13 Apr 1999 p. 1539-40; amended in Gazette 17 Nov 2000 p. 6320; 21 Jan 2005 p. 276; 28 Oct 2005 p. 4919- 20; 18 Nov 2011 p. 4824.] Form 3A [r. 6B] Workers' Compensation and Injury Management Act 1981 (Section 57A(3)(a)) INSURER'S NOTICE THAT LIABILITY IS ACCEPTED To: 1. [name and address of worker to whom the claim relates] 2. [name and address of employer] From: [name and address of insurer] * Claim Number: ............................................. Date of injury by accident or approximate date of onset of condition: Nature of incapacity: Date claim made by employer: ........................................................... In respect of the above claim you are notified that liability is accepted in respect of the weekly payments claimed by the worker. Date on which weekly payments are proposed to commence: [Insurer to liaise with employer to ascertain the commencement date] Signed on behalf of the insurer: Date: ...................................................... * Please provide this claim number to your general practitioner at your next appointment in relation to this claim [Form 3A inserted in Gazette 14 Dec 1999 p. 6151; amended in Gazette 21 Jan 2005 p. 276; 28 Oct 2005 p. 4920.] Form 3B [r. 6C] Workers' Compensation and Injury Management Act 1981 (Section 57A(3)(b)) INSURER'S NOTICE THAT LIABILITY IS DISPUTED To: 1. [name and address of worker to whom the claim relates] 2. [name and address of employer] From: [name and address of insurer] Claim Number: ............................................. Date of injury by accident or approximate date of onset of condition: Nature of incapacity: Date claim made by employer: In respect of the above claim you are notified that liability is disputed in respect of: * all the weekly payments claimed by the worker. * the following weekly payments claimed by the worker. [provide details] The reasons why liability is disputed are as follows: If a reason is that the applicant is not a worker, state the grounds upon which this assertion is made: If a reason is that the applicant did not suffer an injury as defined in section 5(1) of the Act, state the grounds upon which this assertion is made: If a reason is that the injury was not suffered in the course of employment, state the grounds upon which this assertion is made: The provisions of the Workers' Compensation and Injury Management Act 1981 relied on to dispute liability are: Signed on behalf of the insurer. (signature of senior officer responsible for claim) Date: ...................................................... [*delete if appropriate] NOTE THAT if you wish you may - . discuss this notice with the insurer or apply to have the matter heard under any internal dispute resolution process of the insurer; . seek advice in relation to the dispute from WorkCover WA; . if reasonable attempts have been made to resolve the dispute by negotiation with the employer and the insurer, apply to the Director under section 182E of the Act for resolution of a dispute by conciliation; . seek advice or assistance in relation to the dispute from your trade union organisation, a legal practitioner or a registered agent. [Form 3B inserted in Gazette 8 Mar 1991 p. 1074; amended in Gazette 5 Feb 1993 p. 1059; 18 Feb 1994 p. 662; 21 Jan 2005 p. 276; 28 Oct 2005 p. 4921-2; 18 Nov 2011 p. 4824.] Form 3C [r. 6D] Workers' Compensation and Injury Management Act 1981 (Section 57A(3)(c)) INSURER'S NOTICE WHERE NO DECISION ABOUT LIABILITY To: 1. [name and address of worker to whom the claim relates] 2. [name and address of employer] 3. Director From: [name and address of insurer] Claim Number: ............................................. Date of injury by accident or approximate date of onset of condition: Nature of incapacity: Date claim made by employer: ....................................... In respect of the above claim you are notified that a decision as to whether or not liability is to be accepted in respect of the weekly payments claimed by the worker is not able to be made within the time allowed by section 57A(3) of the Act. The reasons why the decision is not able to be made are as follows: Where further medical information is required to make a decision about liability, state the nature and substance of the medical information and whether a written authority from the worker is required: Where further information on the worker's weekly earnings is required to make a decision about liability, state the nature and substance of the information: Where other particulars are required to help make a decision about liability, specify the particulars required: Signed on behalf of the insurer: Date: ........................................................ NOTE THAT if you wish you may - . discuss this notice with the insurer or employer or apply to have the matter heard under any internal dispute resolution process of the insurer; . seek advice in relation to the dispute from WorkCover WA; . if reasonable attempts have been made to resolve the dispute by negotiation with the employer and the insurer, apply to the Director under section 182E of the Act for resolution of a dispute by conciliation; . seek advice or assistance in relation to the dispute from your trade union organisation, a legal practitioner or a registered agent. [Form 3C inserted in Gazette 8 Mar 1991 p. 1075; amended in Gazette 5 Feb 1993 p. 1059; 18 Feb 1994 p. 662; 21 Jan 2005 p. 276; 28 Oct 2005 p. 4922-3; 18 Nov 2011 p. 4824.] Form 3D [r. 6E] Workers' Compensation and Injury Management Act 1981 (Section 57B(2)(b)) UNINSURED OR SELF-INSURED EMPLOYER'S NOTICE THAT LIABILITY IS DISPUTED To: [name and address of worker to whom the claim relates] From: [name and address of uninsured or self-insured employer] Date of injury by accident or approximate date of onset of condition: Nature of incapacity: Date claim made by worker: .......................................................... In respect of the above claim you are notified that liability is disputed in respect of the weekly payments claimed by you. The reasons why liability is disputed are as follows: If a reason is that the applicant is not a worker, state the grounds upon which this assertion is made: If a reason is that the applicant did not suffer an injury as defined in section 5(1) of the Act, state the grounds upon which this assertion is made: If a reason is that the injury was not suffered in the course of employment, state the grounds upon which this assertion is made: The provisions of the Workers' Compensation and Injury Management Act 1981 relied on to dispute liability are: Signed on behalf of the uninsured or self-insured employer (signature of senior officer responsible for claim) Date: ................................................................ NOTE THAT if you wish you may - . discuss this notice with the employer or, if the employer is self insured, apply to have the matter heard under any internal dispute resolution process of the employer; . seek advice in relation to the dispute from WorkCover WA; . if reasonable attempts have been made to resolve the dispute by negotiation with the employer, apply to the Director under section 182E of the Act for resolution of a dispute by conciliation; . seek advice or assistance in relation to the dispute from your trade union organisation, a legal practitioner or a registered agent. [Form 3D inserted in Gazette 8 Mar 1991 p. 1075; amended in Gazette 5 Feb 1993 p. 1059; 18 Feb 1994 p. 662; 21 Jan 2005 p. 276; 28 Oct 2005 p. 4923-4; 18 Nov 2011 p. 4824.] Form 3E [r. 6F] Workers' Compensation and Injury Management Act 1981 (Section 57B(2)(c)) UNINSURED OR SELF-INSURED EMPLOYER'S NOTICE WHERE NO DECISION ABOUT LIABILITY To: 1. [name and address of worker to whom the claim relates] 2. Director From: [name and address of uninsured or self-insured employer] Claim number: ..................................... Date of injury by accident or approximate date of onset of condition: Nature of incapacity: Date claim made by worker: .......................................... In respect of the above claim you are notified that a decision as to whether or not liability to make the weekly payments claimed by the worker is not able to be made within the time allowed by section 57B(2) of the Act. The reasons why the decision is not able to be made are as follows: Where further medical information is required to make a decision about liability, state the nature and substance of the medical information and whether a written authority from the worker is required: Where further information on the worker's weekly earning is required to make a decision about liability, state the nature and substance of the information: Where other particulars are required to help make a decision about liability, specify the particulars required: Signed on behalf of the uninsured or self-insured employer: Date: ................................................. NOTE THAT if you wish you may - . seek advice in relation to the dispute from WorkCover WA; . if reasonable attempts have been made to resolve the dispute by negotiation with the employer, apply to the Director under section 182E of the Act for resolution of a dispute by conciliation; . seek advice or assistance in relation to the dispute from your trade union organisation, a legal practitioner or a registered agent. [Form 3E inserted in Gazette 8 Mar 1991 p. 1075-6; amended in Gazette 5 Feb 1993 p. 1060; 18 Feb 1994 p. 662; 21 Jan 2005 p. 276; 28 Oct 2005 p. 4925-6; 18 Nov 2011 p. 4824-5.] Form 4 [r. 7(1)] Workers' Compensation and Injury Management Act 1981 (Section 61(1)) FINAL MEDICAL CERTIFICATE | |Claim No. | | |(if known) | | | | |To (name and address of | | |worker's employer) | | |WORKER'S DETAILS | | First name(s): .......................................................... Surname: Address: Telephone: Date and place of occurrence of injury: ....../........./......... |MEDICAL ASSESSMENT | | Having examined the worker, it is my opinion that as from ....../........./............ ( the worker has total capacity for work. ( the worker has partial capacity for work. ( the worker's incapacity is no longer a result of the injury. It is also my opinion that as from ....../........./............ the worker is ( fit. ( fit for alternative duties with the following limitations: Grounds for the opinion in medical assessment |MEDICAL PRACTITIONER'S | | |DETAILS | | Name: .......................................................... Registration No.: Address: Telephone: Fax: Signature: .................................................... Time & Date of examination: For workers' compensation information or assistance contact WorkCover WA's Infoline: 1300 794 744 [Form 4 inserted in Gazette 14 Dec 1999 p. 6152; amended in Gazette 17 Nov 2000 p. 6320; 21 Jan 2005 p. 276; 28 Oct 2005 p. 4926.] Form 5 [r. 7(2)] Workers' Compensation and Injury Management Act 1981 NOTICE TO WORKER OF INTENTION TO DISCONTINUE OR REDUCE PAYMENTS (Section 61(1) and (2)) TO: (Name and address of worker) TAKE NOTICE that your employer (name of employer) intends, after 21 clear days from the date of service upon you of this notice, to *discontinue the weekly payments of compensation/reduce the weekly payments on the following basis - (1) this notice is based upon the medical certificates or report(s) of ......................................... dated ......................................... 20 (names of medical practitioners and dates of reports) sent with this notice, in which it is said that (state concisely the ground relied upon by the employer); (2) you may, if you dispute the employer's right to discontinue or reduce the weekly payments within the 21 days referred to in this notice apply for an order of an arbitrator that the weekly payments shall not be discontinued or reduced; (3) if you do not so apply, weekly payments may be lawfully discontinued or reduced; [(4) deleted] (5) you may obtain information from WorkCover WA situated at ....................................................................... ......... as to the ways and means available to you to establish or protect your rights in respect of your injury. Dated the day of 20 . ............................................................... Signed on behalf of the employer. _______________________________________________________________________ * Delete whichever is inapplicable. [Form 5 corrigendum in Gazette 23 Apr 1982 p. 1384; amended in Gazette 8 Mar 1991 p. 1076; 29 Oct 1993 p. 5930; 18 Feb 1994 p. 663; 17 Nov 2000 p. 6320; 21 Jan 2005 p. 276 and 277; 28 Oct 2005 p. 4926.] Form 6 [r. 10(1)] Workers' Compensation and Injury Management Act 1981 (Section 69) DECLARATIONS IN RESPECT OF WORKER NOT RESIDING IN W.A. [ ( = tick where appropriate. * = delete where appropriate] To: (name and address of employer or employer's insurer A. WORKER'S SECTION I, (full name of worker) of (residential address) ............................................................................ ............ Postcode: Occupation: ...........................................................................D ate of birth: ......./......../19 *being duly sworn, say that/do solemnly and sincerely affirm that - 1. The above details about me are correct. 2. I reside at the above address. 3. On ......../......../20...... I suffered an injury when employed by (name and address of employer) *Sworn/affirmed at ) in (State or country) ) this day of 20 ) Before me: (a person having authority to administer an oath) B. DOCTOR'S SECTION I, (full name of medical practitioner) of (address) ............................................................................ ................... Postcode: *being duly sworn, say that/do solemnly and sincerely affirm that - 1. I am a duly qualified medical practitioner. 2. On ........./........../20.......... I examined the above person and am of the opinion that he/she is - (a) ( Fit. (b) ( Fit for alternative duties with the following limitations: (c) ( Totally unfit for work. *Sworn/affirmed at ) in (State or country) ) this day of 20 ) Before me: (a person having authority to administer an oath) IF A WORKER RESIDES OUTSIDE THE STATE, PROOF OF THE WORKER'S IDENTITY AND CONTINUING INCAPACITY IS REQUIRED EVERY 3 MONTHS [Form 6 inserted in Gazette 24 Dec 1993 p. 6849; amended in Gazette 18 Feb 1994 p. 663; 24 Jun 1994 p. 2889; 17 Nov 2000 p. 6320; 21 Jan 2005 p. 276; 28 Oct 2005 p. 4926.] [Form 7 deleted in Gazette 18 Nov 2011 p. 4825.] [Forms 8-11 deleted in Gazette 8 Mar 1991 p. 1076.] [Form 12 deleted in Gazette 18 Feb 1994 p. 663.] [Form 13 deleted in Gazette 28 Oct 2005 p. 4928.] Form 14 [r. 18(1)] Workers' Compensation and Injury Management Act 1981 ELECTION TO RECEIVE REDEMPTION AMOUNT (Schedule 5 clause 3) I, ...............................................................of (name of worker) (address) having attained the age of 65 years on the .............. day of .................................... 20 ....., having suffered from pneumoconiosis/mesothelioma/lung cancer and being entitled to weekly payments of compensation in accordance with Schedule 1 of the Act, elect to receive the redemption amount of $ ..................... as a lump sum. I acknowledge that, by making this election: - 1. I shall have no other claim to redemption of weekly payments. 2. I shall have no claim after the date of this election to weekly payments of compensation. 3. I shall have no further entitlement from the date of this election, to payment of expenses under the Workers' Compensation and Injury Management Act 1981 Schedule 1 clauses 9, 17, 18, 18A and 19 (that is, in general terms, medical and other expenses, hospital charges and travelling costs). 4. Upon my death the provisions of the Workers' Compensation and Injury Management Act 1981 Schedule 1 clauses 1, 1A, 1B, 1C, 2, 3, 4, 5 and 17(2) shall not apply: that is, in general terms dependants of mine, whether totally or partially dependent, shall have no entitlement to payment, benefit, allowance or expenses (funeral or otherwise). Dated the day of 20 . Signed by the worker in the presence of: ................................................................... ................................................................... ................................................................... (Signature and full names of witness). [Form 14 amended in Gazette 8 Mar 1991 p. 1076; 24 Dec 1993 p. 6850; 17 Nov 2000 p. 6320; 21 Jan 2005 p. 276; 28 Oct 2005 p. 4928.] Form 15 [r. 18(2)] Workers' Compensation and Injury Management Act 1981 ELECTION TO RECEIVE SUPPLEMENTARY AMOUNT (Schedule 5 clause 3) I, ............................................................of ......................................................................... (name of worker) (address) having attained the age of 65 years on the ........... day of ................................. 20............ having suffered from pneumoconiosis/mesothelioma/lung cancer and being entitled to weekly payments of compensation in accordance with Schedule 1 of the Act, elect to receive the supplementary amount having *a/*no dependant spouse or dependant de facto partner, being currently the sum of $...................... I acknowledge that, by making this election: - 1. I shall have no other claim to redemption of weekly payments. 2. I shall have no claim after the date of this election to weekly payments of compensation. 3. If my death results from that injury and a dependant spouse or/and a dependant de facto partner survives me then that person is, or those persons are, entitled to all or part of a lump sum calculated in accordance with the Workers' Compensation and Injury Management Act 1981 Schedule 5 clause 7 of the supplementary amount for a worker with a dependent spouse or dependent de facto partner. 4. Upon my death the provisions of the Workers' Compensation and Injury Management Act 1981 Schedule 1 clauses 1, 1A, 1B, 1C, 2, 3, 4, 5 and 17(2) shall not apply: that is, in general terms, dependants of mine, whether totally or partially dependent, shall have no entitlement to any payment, benefit, allowance or expense (funeral or otherwise). Dated the day of 20 . Signed by the worker in the presence of: ................................................................... ................................................................... ................................................................... (Signature and full names of witness). ______________________________________________________________________ * Delete whichever is inapplicable. [Form 15 amended in Gazette 8 Mar 1991 p. 1076; 24 Dec 1993 p. 6850; 17 Nov 2000 p. 6320; 30 Jun 2003 p. 2637-8; 21 Jan 2005 p. 276; 28 Oct 2005 p. 4928-9.] Form 15A [r. 12(4)] Workers' Compensation and Injury Management Act 1981 NOTICE OF MEMORANDUM HAVING BEEN RECEIVED Ref. TAKE NOTICE 1. That a Memorandum, copy of which is hereto annexed, has been sent to me for registration. The Memorandum appears to affect you. 2. I therefore request you to inform me within 7 days from this date whether you admit the genuineness of the Memorandum, or whether you dispute it, and if so, in what particulars, or object to its being recorded, and if so, on what ground. 3. If the Memorandum is recorded it is enforceable as an award or order. 4. If you have any doubts as to the effect of the agreement, or your rights to compensation generally you should contact me immediately. Dated this ................ day of ........................................ 20............... ............................................................... Director [Form 15A inserted in Gazette 18 Feb 1994 p. 663; amended in Gazette 21 Jan 2005 p. 276; 28 Oct 2005 p. 4929; 18 Nov 2011 p. 4825.] Form 15B [r. 12(5)] Workers' Compensation and Injury Management Act 1981 NOTICE OF RECORDING OF MEMORANDUM OF AGREEMENT Ref. YOU ARE NOTIFIED That a memorandum of the agreement entered into between and the abovenamed parties, and dated the ................ day of ................................. 20............. has now been recorded in the Register under section 76 of the Workers' Compensation and Injury Management Act 1981. The Agreement has been numbered .................................. You may, without fee, obtain a certificate of the memorandum and its recording. Dated this .............................. day of ....................................... 20............. ............................................................ Director [Form 15B inserted in Gazette 18 Feb 1994 p. 664; amended in Gazette 21 Jan 2005 p. 276; 28 Oct 2005 p. 4929; 18 Nov 2011 p. 4825.] Form 15C [r. 12(1a)] Workers' Compensation and Injury Management Act 1981 MEMORANDUM OF AGREEMENT (Section 76 & 67(2)) TO: the Director Perth, Western Australia In the matter of an Agreement made the day of (year) Between (Employer) of (address) (WCN Number) and (Worker) of (address) Claim No: Upon the Agreement being recorded pursuant to section 76 of the Workers' Compensation and Injury Management Act 1981 ("the Act") the worker's claims referred to in this Agreement are finalised and the employer shall pay to the worker, and the worker shall accept, the lump sum of $ , upon the terms and conditions as set out in the following - 1. Date of injury Which occurred by: * a personal injury by accident arising out of or in the course of the employment, or whilst the worker was acting under the employer's instructions; * a disabling disease to which Part III Division 3 applies; * a disease contracted by a worker in the course of his/her employment at or away from his/her place of employment and to which the employment was a contributing factor and contributed to a significant degree; * the recurrence, aggravation, or acceleration of any pre-existing disease where the employment was a contributing factor to that recurrence, aggravation, or acceleration and contributed to a significant degree; or * a disabling loss of function to which Part III Division 4 applies. 2. When the disability occurred - (a) the worker was years of age. Date of Birth (b) the worker was employed by the employer as a (c) his or her weekly earnings were 3. The nature of the disability was: and now is: and it occurred in the following circumstances - 4. The worker has received from the employer prior to the date of this Agreement: (a) weekly payments in respect of that disability totalling $ (b) expenses payable under the Workers' Compensation and Injury Management Act 1981 Schedule 1 clauses 9, 10, 17, 18, 18A and 19 Totalling $ ========= 5. The lump sum is made up as follows: *(a) weekly payments of compensation: (i) by way of redemption of liability to make future weekly payments as for permanent total incapacity; $ (ii) by way of redemption of liability to make future weekly payments as for permanent partial incapacity; $ (iii) otherwise; $ *(b) expenses as are provided for in the Workers' Compensation and Injury Management Act 1981 Schedule 1 clauses 9, 10, 17, 18, 18A and 19 namely; $ *(c) the worker having elected under s. 24 of the Act by a form of election dated , compensation payable under Part III Division 2, representing % loss of Item being for the permanent loss of the efficient use of the Totalling: $ *(ca) the worker having elected under section 31C of the Act by a form of election dated ............., compensation payable under the Act Schedule 2 Division 2A, in respect of an impairment mentioned in Schedule 2 item ....., representing ........ degree of permanent impairment from the injury. Totalling: $ *(d) redemption amount under the Workers' Compensation and Injury Management Act 1981 Schedule 5 clause 2 or 3(2), (3) or (4) $ *(e) supplementary amount under the Workers' Compensation and Injury Management Act 1981 Schedule 5 clause 2 or 3(2), (3) or (4) $ TOTAL LUMP SUM $ ========= 6. The employer warrants that to the date of this Agreement it has paid all compensation due to the worker and all expenses in respect of the matters contained in the Workers' Compensation and Injury Management Act 1981 Schedule 1 clauses 9, 10, 17, 18, 18A and 19 (which includes medical and travelling) and, to the extent that these have not been paid, undertakes to pay them. 7. The worker warrants that he/she is not aware of any expenses due but unpaid in respect of the matters contained in the Workers' Compensation and Injury Management Act 1981 Schedule 1 clauses 9, 10, 17, 18, 18A and 19. 8. The worker hereby releases and forever discharges the employer from all claims and demands which the worker now has or, but for the execution of this agreement, could or might have had against the employer under the Act in any respect to the disability to the worker referred to in this Agreement. SIGNED by the worker: in the presence of: SIGNED by or on behalf of the employer: in the presence of- *Delete if not applicable. [Form 15C inserted in Gazette 15 Oct 1999 p. 4907-10; amended in Gazette 17 Nov 2000 p. 6321; 21 Jan 2005 p. 276; 28 Oct 2005 p. 4929- 31; 18 Nov 2011 p. 4825.] Form 15D [r. 12(3a)] Workers' Compensation and Injury Management Act 1981 STATEMENT OF THE CONSEQUENCES OF THE RECORDING OF A MEMORANDUM OF AGREEMENT (Section 76(2)(a)) In making an agreement for the purposes of section 67(l) of the Workers' Compensation and Injury Management Act 1981 ("the Act") and upon that agreement being recorded under section 76 of the Act the following will apply; (1) The worker will have no further entitlement to compensation under the Act for weekly payments arising out of the injury referred to in the agreement. (2) The worker will not have any other claim to redemption of weekly payments arising out of the injury referred to in the agreement. (3) The worker will not have any further entitlement in respect of the injury referred to in the agreement (after the date the agreement is recorded) to payment of expenses under the Workers' Compensation and Injury Management Act 1981 Schedule 1 clauses 9, 17, 18, 18A or 19. That is, in general terms, medical or surgical, dental, physiotherapy or chiropractic advice or treatment, first aid and ambulance expenses, medical requisites, charges for attendance and treatment by way of injury management, charges for hospital treatment and maintenance, cost of artificial aids and travelling expenses. (4) The worker forfeits any entitlement he/she may have under the Act Part III to compensation for a permanent impairment from a compensable personal injury by accident referred to in the agreement. (5) The worker forfeits any chance of a court awarding common law damages against the employer in respect of the injury referred to in the agreement (see section 93E(13) and section 93K(1) of the Act). That is, in general terms, the worker forfeits any chance to recover civil damages from the employer. I , confirm that I have read the above information and I acknowledge that I am aware of the consequences of the recording of a memorandum under section 67(l) of the Act. Dated the day of (year) ....................................... Signature of the worker [Form 15D inserted in Gazette 15 Oct 1999 p. 4910; amended in Gazette 17 Nov 2000 p. 6321; 21 Jan 2005 p. 276; 28 Oct 2005 p. 4931-2.] Form 15E [r. 12(4a)] Workers' Compensation and Injury Management Act 1981 NOTICE DISPUTING MEMORANDUM OF AGREEMENT, OR OBJECTING TO ITS BEING RECORDED (Section 76) In the matter of an Agreement between Employer and Worker Ref. AG TAKE NOTICE that the genuineness of the Memorandum in the abovementioned matter sent to you for registration is disputed by a party affected by such Memorandum, in the following particulars: (here state particulars) (Or that of a party interested in the Memorandum in the above mentioned matter sent to you for registration, objects to the same being recorded, on the following grounds:) (here state grounds) Dated this day of (year) [Form 15E inserted in Gazette 15 Oct 1999 p. 4911; amended in Gazette 17 Nov 2000 p. 6321; 21 Jan 2005 p. 276; 28 Oct 2005 p. 4932.] Form 15F [r. 12(4b)] Workers' Compensation and Injury Management Act 1981 NOTICE THAT MEMORANDUM OF AGREEMENT IS DISPUTED, OR OF OBJECTION TO ITS BEING RECORDED (Section 76) In the matter of an Agreement between Employer and Worker Ref. AG TAKE NOTICE that the genuineness of the Memorandum in the abovementioned matter left with me (or sent to me) for registration is disputed by a party affected by such Memorandum, in the following particulars: (Here state particulars of dispute) (Or that a party interested in the Memorandum in the abovementioned matter, left (or sent to) me for registration objects to the same being recorded, on the following grounds:) (Here state grounds) The Memorandum will therefore not be recorded, except with the consent in writing of or by order of the Registrar. Dated this day of , (year) Director [Form 15F inserted in Gazette 15 Oct 1999 p. 4911-12; amended in Gazette 17 Nov 2000 p. 6321; 21 Jan 2005 p. 276; 28 Oct 2005 p. 4932; 18 Nov 2011 p. 4825.] Form 15G [r. 12AA] Workers' Compensation and Injury Management Act 1981 NOTICE OF INTENTION TO DISMISS WORKER TO WHICH SECTION 84AB OF THE ACT REFERS |TO: (insert name of worker or "WorkCover WA", as | |the case requires) | | | |TAKE NOTICE | |The employer described below intends to dismiss | |the worker described below with effect from the | |following date. | |Date dismissal effective: | |[Note that the date on which the dismissal is | |effective cannot be before a period of 28 days has| |passed after this notice is given to the worker | |and WorkCover WA (see section 84AB of the Workers'| |Compensation and Injury Management Act 1981)]. | Worker's details |Surname | |Other names | | | | | |Date of birth| |Sex | |Occupation | | | | | | | |Address | | | | | |Postcode | |Telephone no. | |WorkCover claim number| | | |(WCCN) | | | | | | | |(if not known, insurer| | | |can provide WCCN) | Employer's details |Name | | | | | |Address | | | | | |Postcode | |Telephone no. | |WorkCover number (WCN)| | | | | |Contact person | | | | | |Title | |Telephone no. | | | | | Insurer's details |Name | | | | | |Address | | | | | |Postcode | |Policy no. | | | | | | | |Contact person | |Telephone no. | | | | | Injury details |Description of injury | | | |Date injury | |Claim number given by | |occurred | |insurer (if known) | | | | | Notice given to | | |worker | | | | | | | |Date |/ | | | | | |/ | | | |(signed on behalf of| | | | | |employer) | | | | |WorkCover | | | | | |WA | |Date |/ | | | | | |/ | | | |(signed on behalf of| | | | | |employer) | | | | [Form 15G inserted in Gazette 28 Oct 2005 p. 4932-4.] Form 16 [r. 15] Workers' Compensation and Injury Management Act 1981 MONTHLY STATEMENT BY APPROVED INSURANCE OFFICES CONFIDENTIAL (Section 171(1)(a)) NEW/RENEWED POLICIES/COVER NOTES Name of approved insurance office Address Chief executive officer, WorkCover WA. The following are the names, addresses and occupations of each employer who has during the month of ........................................................... 20.................................... effected or renewed a policy or contract of insurance with the above office against liability under the Act. |Policy/|New (N)|Name |Address |Occupat|Effectiv|Expiry| |Cover |Renewal| | |ion |e Date |Date | |Note | | | | |(If Less| | |No. |(R) | | | |Than 12 | | | | | | | |Months | | | | | | | |Cover) | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | Position held by officer Date ...................................................... Signature of responsible officer [Form 16 inserted in Gazette 25 Jul 1986 p. 2484; amended in Gazette 8 Mar 1991 p. 1076; 28 Jun 1991 p. 3294; 17 Nov 2000 p. 6321; 16 Sep 2003 p. 4104; 21 Jan 2005 p. 276 and 277.] Form 17 [r. 15] Workers' Compensation and Injury Management Act 1981 MONTHLY STATEMENT BY APPROVED INSURANCE OFFICES CONFIDENTIAL (Section 171(1)(b)) LAPSED POLICIES Name of approved insurance office Address Date approved Chief executive officer, WorkCover WA. The following are the names, addresses and occupations of each employer in respect to whom, during the month of .............................................. 20..................... the above approved insurance office has, in its books, lapsed a policy of insurance under the Act: - |Policy No.|Name |Address |Occupation|Reason | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | Position held by officer ...................................................... Date ....................................... ...................................................... Signature of responsible officer [Form 17 inserted in Gazette 25 Jul 1986 p. 2485; amended in Gazette 8 Mar 1991 p. 1076; 28 Jun 1991 p. 3294; 17 Nov 2000 p. 6321; 16 Sep 2003 p. 4104; 21 Jan 2005 p. 276 and 277; 28 Oct 2005 p. 4934.] Form 18 [r. 19D] Workers' Compensation and Injury Management Act 1981 NOTICE OF ARRANGEMENT OF AUDIOMETRIC TEST TO: (full name of worker) of: (full address of worker) Notice is hereby given that I have arranged for you to undergo an audiometric test to be conducted by (name of person approved under regulation 19B) of (full address at which test is to be conducted) at ................................................ am/pm on .................................................................... (Signature of person arranging test) (name of employer) (date) NON-ATTENDANCE: A worker shall not, without reasonable excuse, fail to submit himself for an audiometric test of which the worker has notice (regulation 19D(3)). PERIOD OF QUIET: An employer shall ensure that the worker is not knowingly exposed in the workplace, and the worker shall not knowingly permit himself to be exposed, to noise levels above 80dB(A) during the 16 hours immediately preceding the audiometric test (regulation 19D(2)). [Form 18 inserted in Gazette 26 Feb 1991 p. 940; amended in Gazette 8 Mar 1991 p. 1076; 21 Jan 2005 p. 276; 28 Oct 2005 p. 4934.] Form 19A [r. 19F] Workers' Compensation and Injury Management Act 1981 REPORT OF BASELINE AUDIOMETRIC TEST TO: Chief executive officer, WorkCover WA. Notice is hereby given that I have conducted an audiometric *test/retest of: WORKER'S DETAILS | | | | | | | | | | | |DATE OF BIRTH | | | | | | | | | | | |EMPLOYED BY: | | | | | | | | | | | |LEVEL OF TEST: | |PURPOSE OF TEST: | |Air-condu| | | |Baselin| | | |ction | | | |e | | | | | |Full | | | | | | | |audiologi| | | | | | | |cal | | | | | | | | | |Medical | | | | | | | |Panel | | | | | | | WAUGH AND MACRAE'S CRITERIA: (Please tick only if worker fails) |Item 1 | | | | |CALCULATED | | | | | |%| |PLH | | | | | | | | |OFFICE USE | PERSON CONDUCTING TEST | | | | | | | | | | | | | | | | | | | | | | |SIGNATURE | |DAY|MONTH |YEAR | * Delete which doesn't apply ** Approved Medical Practitioners or Audiologists Only [Form 19A inserted in Gazette 3 Apr 1992 p. 1542-3; amended in Gazette 21 Jan 2005 p. 276 and 277.] Form 19B [r. 19F] Workers' Compensation and Injury Management Act 1981 REPORT OF SUBSEQUENT/RETIRING/TURNING 65 AUDIOMETRIC TEST TO: Chief executive officer, WorkCover WA. Notice is hereby given that I have conducted an audiometric *test/retest of: WORKER'S DETAILS | | | | | | | | | | | | | |DATE OF BIRTH | | | | | | | | | | | |EMPLOYED OR FORMERLY EMPLOYED BY: | | | | | | | | | | | |LEVEL OF TEST: | |PURPOSE OF TEST: | |Air-condu| | | | | | | |ction | | | | | | | | | |Full | | | |Subsequen| | | |audiologi| | | |t | | | |cal | | | | | | | | | |Medical | | | |Retired/Tur| | | |Panel | | | |ning 65 | | | HEARING TEST RESULTS |HERTZ (Hz) |5|1000 |1500|2|3000 | | |0| | |0| | | |0| | |0| | | | | | |0| | |CALCULATED | | | | |PLH | | | | | | | | | | | | | | |***CALCULAT| | | | | | |ED | | | | | | |NOISE INDUCED | | | PERSON CONDUCTING TEST | | | | | | | | | | | | | | | | | | | | | | |SIGNATURE | |DAY|MONTH|YEAR| * Delete which doesn't apply ** Approved Medical Practitioners or Audiologists Only *** Registered Otorhinolaryngologist Only [Form 19B inserted in Gazette 3 Apr 1992 p. 1544-5; amended in Gazette 21 Jan 2005 p. 276 and 277.] [Form 20 deleted in Gazette 28 Oct 2005 p. 4934.] Form 21 [r. 19H] Workers' Compensation and Injury Management Act 1981 NOTICE OF DISPUTE TO: Chief executive officer, WorkCover WA NAME OF WORKER: ............................................................................ ........................... ADDRESS OF WORKER: ............................................................................ .................... NAME OF EMPLOYER: ............................................................................ ...................... ADDRESS OF EMPLOYER: ............................................................................ ................ I, being an *employer/worker hereby notify you that I dispute the results of an audiometric test conducted on the above worker on (date) ............/............/20................. and request that you arrange a retest of hearing under regulation 19H. ............................................................................ ............ ................................... Signature of Applicant Date * Strike out whichever does not apply. [Form 21 inserted in Gazette 26 Feb 1991 p. 946; amended in Gazette 8 Mar 1991 p. 1076; 21 Jan 2005 p. 276 and 277.] Form 22 [r. 19J(1)] Workers' Compensation and Injury Management Act 1981 REFERRAL OF QUESTION OF DEGREE OF DISABILITY Worker's details |Surname | |Other names | | | | | |Date of | |Sex | |Occupation | |birth | | | | | | | | | | | |Address | | | | | |Postcode | |Telephone no. | | | | | Employer's details |Name | | | | | |Address | | | | | |Postcode | |Telephone no. | |WorkCover no. (if | | | |known) | | | | | |Contact person | | | |Title | |Telephone no. | | | | | Insurer's details |Name | | | | | |Address | | | | | |Postcode | |Date weekly payments | |Claim no. (if known) | |commenced (if | | | |applicable). | | | | | | | |Contact person | | | |Telephone no. | | | | | | | Injury details |Description of injury | | | | | |Date injury | |Date weekly payments | |occurred | |commenced | | | | | |Degree of | |Degree of disability (see | |disability as | |s. 93E(3) of the Act) | |assessed by | |Nominate only one of the | |medical | |following. | |practitioner | |( not less than 30% | | | |( not less than 16% | | | | | |Tick if the worker and the employer cannot| | |agree on whether the degree of disability |( | |is not less than the relevant level | | |The action taken by or on behalf of the worker to | |obtain the employer's agreement | | | | | | | | | | | |Signature| |Date | | | |of worker| | |/ | | | | | |/ | | | | | | | | |Lodging this form | |This form should be lodged with - | |Director | |WorkCover WA | |Perth, Western Australia | |You must also give to the Director medical | |evidence from a medical practitioner indicating | |that, in his or her opinion, your degree of | |disability is not less than the relevant level. | [Form 22 inserted in Gazette 14 Dec 1999 p. 6153-4; amended in Gazette 17 Nov 2000 p. 6321; 21 Jan 2005 p. 276; 28 Oct 2005 p. 4934- 5; 18 Nov 2011 p. 4825.] Form 22A [r. 19JA] Workers' Compensation and Injury Management Act 1981 REFERRAL OF QUESTION OF DEGREE OF DISABILITY [Made by the worker under sections 93D(5) and 93EA(3) of the Act, due to the application of section 93EA(3)] Worker's details |Surname | |Other names | | | | | |Date of | |Sex | |Occupation | |birth | | | | | | | | | | | |Address | | | | | |Postcode | |Telephone no. | | | | | Employer's details |Name | | | | | |Address | | | | | |Postcode | |Telephone no. | |WorkCover no. (if | | | |known) | | | | | |Contact person | | | |Title | |Telephone no. | | | | | Insurer's details |Name | | | | | |Address | | | | | |Postcode | | | |Date weekly payments | |Claim no. (if known) | |commenced (if | | | |applicable) | | | | | | | |Contact person | | | |Telephone no. | | | | | | | Injury details |Description of injury | |Note: This must be the same injury and only that | |injury that was the subject of a referral in the | |circumstances set out in section 93EA(1) of the | |Act. | | | | | |Date injury | |Date weekly payments | |occurred | |commenced | | | | | |Degree of | |Degree of disability (see | |disability as | |s. 93E(3) of the Act) | |assessed by | |Nominate only one of the | |medical | |following | |practitioner | |( not less than 30% | | | |( not less than 16% | | | | | Note: The nominated level must be the same level as was nominated in the original referral. If the original referral was pre 14 December 1999 and both levels were nominated, the nominated level should be one of those levels, and a further Form 22A may be used for the other level, if required. |Tick if the worker and the employer cannot| | |agree on whether the degree of disability |( | |is not less than the relevant level | | |The action taken by or on behalf of the worker to | |obtain the employer's agreement | | | | | | | | | |The following information should be | | |included with this referral - | | |If, on or before 30 September 2001, you | | |sought to refer a question to the | | |Director under section 93D(5) of the Act,| | |and in order to satisfy section 93D(6) of| | |the Act you produced to the Director |( | |anything that, even though it may not | | |have constituted evidence of the kind | | |required by that subsection, was accepted| | |by the Director as evidence of that kind,|( | |then a copy of the Form 22 that was | | |referred to and accepted by the Director | | |should be attached. | | | | | |If, based on a failure to satisfy the |( | |requirements of section 93D(6), a review | | |officer did not deal with the substance | | |of the question referred to above, a copy| | |of the review officer's decision should | | |be attached; | | |or | | |If, based on a failure to satisfy the | | |requirements of section 93D(6), a court | | |set aside or quashed a decision of a | | |review officer that dealt with the | | |substance of the question referred to in | | |the first paragraph above, a copy of the | | |court decision should be attached. | | |The following details must be completed regarding | |the medical evidence relied upon in support of | |this referral - | |Name of Medical Practitioner/s |Date of medical | | |report/s | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |Note: Under section 93EA(4)(c) of the Act, this | |form is to be accompanied by a copy of the medical| |evidence that complies with section 93D(6) of the | |Act, unless the worker satisfies the Director that| |the complying evidence has already been produced. | | | |Signature| | | | | |of worker|_____________________|Date |/ | | | |___________ | |/ | | | | | | | | |Lodging this form | |This form should be lodged with - | |Director | |WorkCover WA | |Perth, Western Australia | [Form 22A inserted in Gazette 26 Oct 2004 p. 4902-5; amended in Gazette 21 Jan 2005 p. 276; 28 Oct 2005 p. 4935; 18 Nov 2011 p. 4825.] Form 22B [r. 19JB] Workers' Compensation and Injury Management Act 1981 REFERRAL OF QUESTION OF DEGREE OF DISABILITY [Made by the worker under sections 93D(5) and 93EB(3) of the Act, due to the application of section 93EB(3)] Worker's details |Surname | |Other names | | | | | |Date of | |Sex | |Occupation | |birth | | | | | | | | | | | |Address | | | | | |Postcode | |Telephone no. | | | | | Employer's details |Name | | | | | |Address | | | | | |Postcode | |Telephone no. | |WorkCover no. (if | | | |known) | | | | | |Contact person | | | |Title | |Telephone no. | | | | | Insurer's details |Name | | | | | |Address | | | | | |Postcode | |Date weekly payments | |Claim no. (if known) | |commenced (if | | | |applicable) | | | | | | | |Contact person | | | |Telephone no. | | | | | | | Injury details |Description of injury | |Note: This must be the same injury and only that | |injury that was the subject of a referral in the | |circumstances set out in section 93EB(1) of the | |Act. | | | | | |Date injury | |Date weekly payments | |occurred | |commenced | | | | | |Degree of | |Degree of disability (see | |disability as | |s. 93E(3) of the Act) | |assessed by | |Nominate only one of the | |medical | |following | |practitioner | |( not less than 30% | | | |( not less than 16% | | | | | Note: The nominated level must be the same level as was nominated in the original referral. If the original referral was pre 14 December 1999 and both levels were nominated, the nominated level should be one of those levels, and a further Form 22B may be used for the other level, if required. |Tick if the worker and the employer cannot| | |agree on whether the degree of disability |( | |is not less than the relevant level | | |The action taken by or on behalf of the worker to | |obtain the employer's agreement | | | | | | | | | |The following information should be | | |included with this referral - | | |If, before the commencement of section 10| | |of the Workers' Compensation (Common Law | | |Proceedings) Act 2004, you sought to |( | |refer a question to the Director under | | |section 93D(5) of the Act, then a copy of| | |the Form 22 that was referred to and | | |accepted by the Director should be | | |attached. | | | | | |If, on or after 4 December 2003, on the |( | |basis that Part IV Division 2 as in force| | |before it was amended by section 32 of | | |the Workers' Compensation and | | |Rehabilitation Amendment Act 1999 applied| | |to proceedings for the awarding of | | |damages concerned, a review officer did | | |not deal with the substance of the |( | |question referred to above, a copy of the| | |review officer's decision should be | | |attached; | | |or | | |If, on or after 4 December 2003, on the | | |basis that Part IV Division 2 as in force| | |before it was amended by section 32 of | | |the Workers' Compensation and | | |Rehabilitation Amendment Act 1999 applied| | |to proceedings for the awarding of | | |damages concerned, a court set aside or | | |quashed a decision of a review officer | | |that dealt with the substance of the | | |question referred to in the first | | |paragraph above, a copy of the court | | |decision should be attached. | | |The following details must be completed regarding | |the medical evidence relied upon in support of | |this referral - | |Name of Medical Practitioner/s |Date of medical | | |report/s | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |Note: Under section 93EB(4)(c) of the Act, this | |form is to be accompanied by a copy of the medical| |evidence that complies with section 93D(6) of the | |Act, unless the worker satisfies the Director that| |the complying evidence has already been produced. | | | |Signatur| | | | | |e of | |Date |/ | | |worker | | |/ | | | | | | | | |Lodging this form | |This form should be lodged with - | |Director | |WorkCover WA | |Perth, Western Australia | [Form 22B inserted in Gazette 26 Oct 2004 p. 4905-8; amended in Gazette 21 Jan 2005 p. 276; 28 Oct 2005 p. 4936; 18 Nov 2011 p. 4825.] Form 23 [r. 19J(2), (3)] Workers' Compensation and Injury Management Act 1981 NOTICE OF REFERRAL OF QUESTION OF DEGREE OF DISABILITY Worker's details |Surname | |Other names | | | | | |Address | | | | | |Postcode | |Telephone no. | |Occupation | | | | | Employer's details |Name | | | | | |Address | | | | | |Postcode | |Telephone no. | |WorkCover no. (if | | | |known) | | | | | Injury details |Description of injury | | | |Date injury | | | |occurred | | | | | | | |Degree of | |Degree of disability | |disability as | | | |assessed by | | | |medical | | | |practitioner | | | | | |( |not less than 30% | | | |( |not less than 16% | | | | | | |Question referred | |The question of whether the worker's degree of | |disability is or is not less than the relevant | |level has been referred to the Director, for | |consideration. | |Medical evidence | |Accompanying this notice is a copy of the medical | |evidence provided by the worker which indicates | |that in the opinion of the worker's medical | |practitioner the worker's degree of disability is | |not less than the relevant level. | |Objection | |If you (the employer) consider the worker's degree| |of disability is less than the relevant level, you| |should complete the bottom section of this form | |and return it to the Director within 21 days of | |receiving this notice. | |If you do not notify the Director within 21 days | |you will be taken to have agreed that the worker's| |degree of disability is not less than the relevant| |level | | | |Signature| | | | | |of | |Date |/ | | |Director | | |/ | | | | | | | | Employer's objection |Employer's assessment of| | | |degree of disability | | | | | |Signature | | | | | |of | |Date |/ | | |employer | | |/ | | | | | | | | [Form 23 inserted in Gazette 14 Dec 1999 p. 6154-5; amended in Gazette 17 Nov 2000 p. 6321; 21 Jan 2005 p. 276; 28 Oct 2005 p. 4936- 7; 18 Nov 2011 p. 4825.] Form 23A [r. 19JA] Workers' Compensation and Injury Management Act 1981 NOTICE OF REFERRAL OF QUESTION OF DEGREE OF DISABILITY [Notice given under section 93EA(5)(a) and (b)(i) of the Act, where section 93EA(3) applied] Worker's details |Surname | |Other names | | | | | |Address | | | | | |Postcode | |Telephone no. | |Occupation | | | | | Employer's details |Name | | | | | |Address | | | | | |Postcode | |Telephone no. | |WorkCover no. (if | | | |known) | | | | | Injury details |Description of injury | | | |Date injury | | | |occurred | | | | | | | |Degree of | |Degree of disability | |disability as | | | |assessed by | | | |medical | | | |practitioner | | | | | |( |not less than 30% | | | |( |not less than 16% | | | | | | |Question referred | |The question of whether the worker's degree of | |disability is or is not less than the relevant | |level has been referred to the Director, for | |consideration under section 93D(5), due to the | |application of section 93EA(3). | |Medical evidence | |Accompanying this notice is a copy of the medical | |evidence produced by the worker that complies with| |section 93D(6) of the Act. | |Director's opinion | |In accordance with section 93EA(5)(a) and (b)(i) | |of the Act, it is my opinion that - | |(a)|evidence complying with section 93D(6)| | | |has been produced and in all other |( | | |respects the referral is properly | | | |made; and | | |(b)|the referral is accepted. |( | | | |In accordance with section 93EA(5)(b)(i) of the | |Act, notification is also given that the following| |provisions may apply - | |Section 93E(6a) | | | |Note: Section 93E(6a) provides that, despite | | |section 93E(5), and even though section 93E(6)| | |does not apply if the Director gives the | | |worker notice under section 93EA(5)(b)(i) that| | |this subsection applies, an election can be | | |made within 14 days after the Director | | |subsequently gives the worker notice in | | |writing that an agreement or determination of | | |the question has been recorded. This only | | |applies if the worker is required to make an | | |election under section 93E(3)(b) of the Act | | |(i.e. the worker has an agreed or determined | | |degree of disability of not less than 16% but | | |less than 30%). | | | | |Section 93EC | | | |Note: If - | | (a) |under section 93EA(5)(b)(i), the | | | |Director notifies a worker that | | | |the referral of a question | | | |relating to an injury is accepted | | | |and that this section applies; and| | | (b) |the time limited by any written | | | |law for the commencement of an | | | |action seeking damages in respect | | | |of the injury - | | | (i) |has elapsed before the day on | | | |which the Director notifies the| | | |worker (the "notification" | | | |day); or | | | (ii) |is due to elapse on the | | | |notification day or before the | | | |expiry of a period of 2 years | | | |after the notification day, | | | |an action seeking damages in respect of the | | |injury may, despite that written law, be | | |commenced at any time before the expiry of a | | |period of 2 years after the notification day. | |Objection | |If you (the employer) consider the worker's degree| |of disability is less than the relevant level, you| |should complete the bottom section of this form | |and return it to the Director within 21 days of | |receiving this notice. | |If you do not notify the Director within 21 days | |you will be taken to have agreed that the worker's| |degree of disability is not less than the relevant| |level. | | | |Signature| | | | | |of | |Date |/ | | |Director | | |/ | | | | | | | | Employer's objection |Employer's assessment of| | | |degree of disability | | | | | |Signature | | | | | |of | |Date |/ | | |employer | | |/ | | | | | | | | [Form 23A inserted in Gazette 26 Oct 2004 p. 4908-10; amended in Gazette 21 Jan 2005 p. 276; 28 Oct 2005 p. 4937-8; 9 Dec 2005 p. 5897; 18 Nov 2011 p. 4825.] Form 23B [r. 19JB] Workers' Compensation and Injury Management Act 1981 NOTICE OF REFERRAL OF QUESTION OF DEGREE OF DISABILITY [Notice given under section 93EB(5)(a) and (b)(i) of the Act, where section 93EB(3) applied] Worker's details |Surname | |Other names | | | | | |Address | | | | | |Postcode | |Telephone no. | |Occupation | | | | | Employer's details |Name | | | | | |Address | | | | | |Postcode | |Telephone no. | |WorkCover no. (if | | | |known) | | | | | Injury details |Description of injury | | | |Date injury | | | |occurred | | | | | | | |Degree of | |Degree of disability | |disability as | | | |assessed by | | | |medical | | | |practitioner | | | | | |( |not less than 30% | | | |( |not less than 16% | | | | | | |Question referred | |The question of whether the worker's degree of | |disability is or is not less than the relevant | |level has been referred to the Director, for | |consideration under section 93D(5), due to the | |application of section 93EB(3). | |Medical evidence | |Accompanying this notice is a copy of the medical | |evidence produced by the worker that complies with| |section 93D(6) of the Act. | |Director's opinion | |In accordance with section 93EB(5)(a) and (b)(i) | |of the Act, it is my opinion that - | |(a)|evidence complying with section 93D(6)| | | |has been produced and in all other |( | | |respects the referral is properly | | | |made; and | | |(b)|the referral is accepted. |( | | | |In accordance with section 93EB(5)(b)(i) of the | |Act, notification is also given that the following| |provisions may apply - | |Section 93E(6a) | | | |Note: Section 93E(6a) provides that, despite | | |section 93E(5), and even though section 93E(6)| | |does not apply if the Director gives the | | |worker notice under section 93EB(5)(b)(i) that| | |this subsection applies, an election can be | | |made within 14 days after the Director | | |subsequently gives the worker notice in | | |writing that an agreement or determination of | | |the question has been recorded. This only | | |applies if the worker is required to make an | | |election under section 93E(3)(b) of the Act | | |(i.e. the worker has an agreed or determined | | |degree of disability of not less than 16% but | | |less than 30%). | |Section 93EC | | | |Note: If - | | (a) |under section 93EB(5)(b)(i), the | | | |Director notifies a worker that the| | | |referral of a question relating to | | | |an injury is accepted and that this| | | |section applies; and | | | (b) |the time limited by any written law| | | |for the commencement of an action | | | |seeking damages in respect of the | | | |injury - | | | (i) |has elapsed before the day on | | | |which the Director notifies the| | | |worker (the "notification | | | |day"); or | | | (ii) |is due to elapse on the | | | |notification day or before the | | | |expiry of a period of 2 years | | | |after the notification day, | | | |an action seeking damages in respect of the | | |injury may, despite that written law, be | | |commenced at any time before the expiry of a | | |period of 2 years after the notification day. | |Objection | |If you (the employer) consider the worker's degree| |of disability is less than the relevant level, you| |should complete the bottom section of this form | |and return it to the Director within 21 days of | |receiving this notice. | |If you do not notify the Director within 21 days | |you will be taken to have agreed that the worker's| |degree of disability is not less than the relevant| |level. | | | |Signature| | | | | |of | |Date |/ | | |Director | | |/ | | | | | | | | Employer's objection |Employer's assessment of| | | |degree of disability | | | | | |Signature | | | | | |of | |Date |/ | | |employer | | |/ | | | | | | | | [Form 23B inserted in Gazette 26 Oct 2004 p. 4911-13; amended in Gazette 21 Jan 2005 p. 276; 28 Oct 2005 p. 4937-8; 9 Dec 2005 p. 5897; 18 Nov 2011 p. 4825.] Form 24 [r. 19K(1), (2)] Workers' Compensation and Injury Management Act 1981 DEGREE OF DISABILITY AGREEMENT Worker's details |Surname | |Other names | | | | | |Address | | | | | |Postcode | |Telephone no. | |Occupation | | | | | Employer's details |Name | | | | | |Address | | | | | |Postcode | |Telephone no. | |WorkCover no. (if | | | |known) | | | | | Insurer's details |Name | | | | | |Address | | | | | |Postcode | |Date weekly payments | |Claim no. (if known) | |commenced (if | | | |applicable). | | | | | | | |Contact person | | | |Telephone no. | | | | | | | Injury details |Description of injury | | | | | |Date injury | | | |occurred | | | | | | | Agreement |Agreed degree of | % | |Agreed degree of | |disability | | |disability is - | |(insert actual | | |( not less than 30% | |figure e.g. 22%)| | |( not less than 16% | | | | | | |Signature | | | | | |of Worker | |Date |/ | | | | | |/ | | | | | | | | |Signature | |Name | | | |of witness| |of | | | | | |witne| | | | | |ss | | | | | | | | | | | | | | | |Signature | | | | | |of | |Date |/ | | |Employer | | |/ | | | | | | | | |Signature | |Name | | | |of witness| |of | | | | | |witne| | | | | |ss | | | | | | | | | Recording of agreement |Date of recording | |Record no. | | | | | | | |Signature | | | | | |of | |Date |/ | | |Director | | |/ | | | | | | | | [Form 24 inserted in Gazette 14 Dec 1999 p. 6156-7; amended in Gazette 17 Nov 2000 p. 6321; 21 Jan 2005 p. 276; 28 Oct 2005 p. 4938.] Form 25 [r. 19M(1)] Workers' Compensation and Injury Management Act 1981 ELECTION TO RETAIN RIGHT TO SEEK DAMAGES Worker's details |Surname | |Other names | | | | | |Date of | |Sex | |Occupation | |birth | | | | | | | | | | | |Address | | | | | |Postcode | |Telephone no. | | | | | | | Employer's details |Name | | | | | |Address | | | | | |Postcode | |Telephone no. | |WorkCover no. (if | | | |known) | | | | | |Contact person | | | |Title | |Telephone no. | | | | | Insurer's details |Name | | | | | |Address | | | | | |Postcode | |Date weekly payments | |Claim no. (if known) | |commenced | | | | | | | |Contact person | | | |Telephone no. | | | | | | | Injury details |Description of injury | | | |Date injury | | | |occurred | | | | | | | |Has a Degree of Disability Agreement |Yes ( | |(Form 24) already been recorded by the|No ( | |Director? | | |If yes: | | |..............................date | | |when recorded | | |..............................record | | |number | | |Degree of disability as | | |agreed................................| | |.% | | |Has the determination of a dispute as |Yes ( | |to the degree of disability already |No ( | |been recorded under reg. 19L by the | | |Director? | | |If yes: ..............................date when | |recorded | |..............................record number | |Degree of disability as | |determined.........................% | Advice of consequences of election |I have been properly advised of the consequences | |of this election. | | | |Signatur| | | | | |e of | |Date |/ | | |Worker | | |/ | | | | | | | | |Warning | |The registration of this election will, in most | |cases, prevent you from continuing to receive | |statutory benefits under the Workers' Compensation| |and Injury Management Act 1981. | |You should seek appropriate independent advice | |before lodging this form. | Registration of election |Date of | |Registration no. | |registration | | | | | | | | | |Signature| | | | | |of | |Date |/ | | |Director | | |/ | | | | | | | | [Form 25 inserted in Gazette 14 Dec 1999 p. 6157-9; amended in Gazette 17 Nov 2000 p. 6317 and 6321; 21 Jan 2005 p. 276; 28 Oct 2005 p. 4938.] Form 26 [r. 19N(3)(a) and (5)(a)] Workers' Compensation and Injury Management Act 1981 APPLICATION FOR EXTENSION OF TIME TO MAKE ELECTION (MEDICAL EVIDENCE AVAILABLE) Worker's details |Surname | |Other names | | | | | |Date of | |Sex | |Occupation | |birth | | | | | | | | | | | |Address | | | | | |Postcode | |Telephone no. | | | | | | | Employer's details |Name | | | | | |Address | | | | | |Postcode | |Telephone no. | |WorkCover no. (if | | | |known) | | | | | |Contact person | | | |Title | |Telephone no. | | | | | Insurer's details |Name | | | | | |Address | | | | | |Postcode | |Date weekly payments | |Claim no. (if known) | |commenced | | | | | | | |Contact person | | | |Telephone no. | | | | | | | Injury details |Description of injury | | | | | |Degree of disability | |Date injury | |(as assessed by worker's | |occurred | |medical specialist) | | | | % | Extension of time sought |The application for extension of time is | |made under - | |( regulation 19N(2)(a) | |OR ( | |regulation 19N(2)(c) | |Extension | | |sought until | | | | |Signatur| | | | | |e of | |Date |/ | | |Worker | | |/ | | | | | | | | |Lodging this form | |This form should be lodged with - | |Director | |WorkCover WA | |Perth, Western Australia | |If applying under regulation 19N(2)(a) you must | |also give to the Director medical evidence from a | |medical practitioner who is a specialist in a | |relevant field of medicine indicating that you | |will require major surgery in the extension period| |(see regulation 19N(1)). | |If applying under regulation 19N(2)(c) you must | |give the Director evidence of the medical panel's | |determination. | Granting of extension |An extension of time to make an election | |under section 93E(3)(b) of the Act - | |( is granted until / / | |OR ( is not granted | |The extension of time is granted under -| | | |( regulation 19N(2)(a) | |OR ( | |regulation 19N(2)(c) | | | |Signature| | | | | |of | |Date |/ | | |Director | | |/ | | | | | | | | [Form 26 inserted in Gazette 14 Dec 1999 p. 6159-61; amended in Gazette 17 Nov 2000 p. 6321; 21 Jan 2005 p. 276; 28 Oct 2005 p. 4938- 9; 18 Nov 2011 p. 4825.] Form 27 [r. 19N(4)(a)] Workers' Compensation and Injury Management Act 1981 APPLICATION FOR EXTENSION OF TIME TO MAKE ELECTION (MEDICAL EVIDENCE NOT YET AVAILABLE) Worker's details |Surname | |Other names | | | | | |Date of | |Sex | |Occupation | |birth | | | | | | | | | | | |Address | | | | | |Postcode | |Telephone no. | | | | | | | Employer's details |Name | | | | | |Address | | | | | |Postcode | |Telephone no. | |WorkCover no. (if | | | |known) | | | | | |Contact person | | | |Title | |Telephone no. | | | | | Insurer's details |Name | | | | | |Address | | | | | |Postcode | |Date weekly payments | |Claim no. (if known) | |commenced | | | | | | | |Contact person | | | |Telephone no. | | | | | | | Injury details |Description of injury | | | |Date injury | | | |occurred | | | | | | | Extension of time sought |Extension | | |sought until | | |State grounds on which the worker submits that he | |or she will require major surgery in respect of | |the injury in the extension period (see | |regulation 19N(1)) | | | | | | | | | |State the action that has been taken by or on | |behalf of the worker to obtain medical evidence | |from a medical practitioner who is a specialist in| |a relevant field of medicine that the worker will | |require major surgery in respect of the injury in | |the extension period | | | | | | | |(attach separate sheet if insufficient room) | | | |Signatur| | | | | |e of | |Date |/ | | |Worker | | |/ | | | | | | | | |Lodging this form | |This form should be lodged with - | |Director | |WorkCover WA | |Perth, Western Australia | |You must also give to the Director any further | |evidence that the Director may request in relation| |to this application. | Granting of extension |An extension of time to make an election | |under section 93E(3)(b) of the Act - | |( is granted until / / | |OR ( is not granted | | | |Signature| | | | | |of | |Date |/ | | |Director | | |/ | | | | | | | | [Form 27 inserted in Gazette 14 Dec 1999 p. 6161-3; amended in Gazette 17 Nov 2000 p. 6321; 21 Jan 2005 p. 276; 28 Oct 2005 p. 4939; 18 Nov 2011 p. 4825.] Form 28 [r. 19N(3a)(a)] Workers' Compensation and Injury Management Act 1981 APPLICATION FOR EXTENSION OF TIME TO MAKE ELECTION (TIME NEEDED FOR REPORT BASED ON TREATMENT OR MEDICAL INVESTIGATION) Worker's details |Surname | |Other names | | | | | |Date of | |Sex | |Occupation | |birth | | | | | | | | | | | |Address | | | | | |Postcode | |Telephone no. | | | | | | | Employer's details |Name | | | | | |Address | | | | | |Postcode | |Telephone no. | |WorkCover no. (if | | | |known) | | | | | |Contact person | | | |Title | |Telephone no. | | | | | Insurer's details |Name | | | | | |Address | | | | | |Postcode | |Date weekly payments | |Claim no. (if known) | |commenced | | | | | | | |Contact person | | | |Telephone no. | | | | | | | Injury details |Description of injury | | | |Date injury | | | |occurred | | | | | | | Extension of time sought |Extension | | |sought until | | |The extension is needed to give sufficient time | |for the preparation of a specialist's report, | |based on treatment or medical investigation of the| |worker, as to whether the worker will require | |major surgery in respect of the injury in the | |extension period (see regulation 19N(1)). The | |treatment or medical investigation is (describe | |below): | | | | | | | | | | | |Signatur| | | | | |e of | |Date |/ | | |Worker | | |/ | | | | | | | | |Lodging this form | |This form should be lodged with - | |Director | |WorkCover WA | |Perth, Western Australia | |You must also give to the Director medical | |evidence from a specialist in a relevant field of | |medicine indicating that a report could not be | |satisfactorily prepared without the treatment or | |investigation having been carried out, and that | |the extension sought is needed to give sufficient | |time for the preparation of the report | Granting of extension |An extension of time to make an election | |under section 93E(3)(b) of the Act - | |( is granted until / / | |OR ( is not granted | | | |Signature| | | | | |of | |Date |/ | | |Director | | |/ | | | | | | | | [Form 28 inserted in Gazette 17 Nov 2000 p. 6317-19; amended in Gazette 21 Jan 2005 p. 276; 28 Oct 2005 p. 4939; 18 Nov 2011 p. 4825.] Form 29 [r. 16A(1)] Workers' Compensation and Injury Management Act 1981 (Schedule 1 clause 1C(1), (5)) NOTICE OF DEPENDANT'S ENTITLEMENT TO ELECT Record No. | | TO: 1. Dependant's details | Surname | |Other names | | | | | | Address | | | | | | | |Postcode | As a dependant referred to in the Workers' Compensation and Injury Management Act 1981 Schedule 1 clause 1B(1)(a) or (c) you are entitled to elect to receive a child's allowance under that Act Schedule 1 clause 1A or an apportionment of the notional residual entitlement of ...................................................................... ................ . (name of deceased worker) You may, within 30 days of receiving this notification, elect to receive the amount of the apportionment or a child's allowance. A form for making the election is attached. If an election is not made within 30 days of receiving this notification, and registered by the Director, you will receive a child's allowance. The Director may refuse to register the election if not satisfied that you have been independently advised of the financial consequences of the election. Dated this ..................... day of ................ 20......... ...................................................................... ....... Director [Form 29 inserted in Gazette 28 Oct 2005 p. 4939-40; amended in Gazette 18 Nov 2011 p. 4825.] Form 30 [r. 16A(2)] Workers' Compensation and Injury Management Act 1981 (Schedule 1 clause 1C(4)(a), (5)) NOTICE OF PROVISIONAL APPORTIONMENT Record No. | | | | TO: 1. Dependant's details | Surname | |Other names | | | | | | Address | | | | | | | |Postcode | As a dependant of ...................................................................... .................. (name of deceased worker) The notional residual entitlement in relation to ........................................... (name of deceased worker) has been apportioned between the worker's dependants under the Workers' Compensation and Injury Management Act 1981 Schedule 1 clause 1C(4)(a). The amount provisionally apportioned to you is $ ......................................... . You may, within 30 days of receiving this notification, elect to receive the amount of the provisional apportionment or a child's allowance. A form for making the election is attached. If an election is not made within 30 days of receiving this notification, and registered by the Director, you will receive a child's allowance. The Director may refuse to register the election if not satisfied that you have been independently advised of the financial consequences of the election. Dated this ..................... day of ................ 20......... ...................................................................... ....... Arbitrator [Form 30 inserted in Gazette 28 Oct 2005 p. 4941.] Form 31 [r. 17AD(2)] Workers' Compensation and Injury Management Act 1981 APPLICATION TO EXTEND FINAL DAY [for extension under Schedule 1 clause 18B] Worker's details |Surname | |Other names | | | | | |Date of birth| |Sex | |Occupation | | | | | | | |Address | | | | | |Postcode | |Telephone no. | |WorkCover claim number| | | |(WCCN) | | | | | | | |(if not known, insurer| | | |can provide WCCN) | Employer's details |Name | | | | | |Address | | | | | |Postcode | |Telephone no. | |WorkCover number (WCN)| | | | | |Contact person | | | | | |Title | |Telephone no. | | | | | Insurer's details |Name | | | | | |Address | | | | | |Postcode | |Date the claim for | | | |compensation by way of | |Claim number given by | |weekly payments was made| |insurer (if known) | |on employer | | | | | | | |Contact person | |Telephone no. | | | | | Final day |1. Did a dispute resolution authority, acting | |under section 58(1) or (2) of the Act, determine | |the question of liability to make the weekly | |payments claimed? | | |Yes |( |If so, answer question 2.| | |No |( |If not, skip question 2. | |2. Was the question determined more than 3 months | |after the day on which compensation by way of | |weekly payments was claimed? | | |Yes |( |If so, on | | | | | | |which date? | | | | |No |( | | | |3. Was the worker first notified that liability is| |accepted in respect of the weekly payments claimed| |more than 3 months after the day on which | |compensation by way of weekly payments was | |claimed? | | |Yes |( |If so, on | | | | | | |which date? | | | | |No |( | | |4. Has the final day been extended under the | |Workers' Compensation and Injury Management | |Act 1981 Schedule 1 clause 18B? | | |Yes |( |If so, to | | | | | | |which date? | | | | |No |( | | | Extension sought |1. Specify the reasons for seeking the extension. | | | | | | | | | | | | | | | | | |2. Has the worker, in accordance with the | |regulations and before the final day, requested an| |approved medical specialist to assess the worker's| |degree of permanent whole of person impairment? | | |Yes |( |If so, on | | | | | | |which date? | | | | |No |( | | |Attach a copy of any such request. | |3. Specify date until | | | | |which extension sought. | | | | | | |Signature| | | | | |of worker| |Date |/ | | | | | |/ | | | | | | | | How to lodge this form |1. This form should be lodged with: | | |Director | | |WorkCover WA | | |Perth, WA | |2. WHEN LODGING THIS FORM ALSO PROVIDE ANYTHING | |ELSE THAT REGULATION 17AD REQUIRES YOU TO PROVIDE.| Extension given or refused |The final day | | |is | | / | | | |extended | |/ | | | |to | | | | | |is not |( | | | |extended. | | | |Signature| | | | | |of | |Date |/ | | |Director | | |/ | | | | | | | | Copies of extension sent to | | |worker | | | | | | | |Date |/ | | | | | |/ | | | |(signature of person | | | | | |sending copy) | | | | |employer | | | | | | | |Date |/ | | | | | |/ | | | |(signature of person | | | | | |sending copy) | | | | Note |Section 93E(14) of the Workers' Compensation and | |Injury Management Act 1981 provides that if a | |further additional sum has been allowed to a | |worker under Schedule 1 clause 18A(1b) of that Act| |in relation to an injury that is compensable under| |the Act, damages are not to be awarded in respect | |of the injury. | [Form 31 inserted in Gazette 28 Oct 2005 p. 4942-4; amended in Gazette 18 Nov 2011 p. 4825.] Form 32 [r. 20] Workers' Compensation and Injury Management Act 1981 RECORD OF AGREEMENT ABOUT DEGREE OF PERMANENT WHOLE OF PERSON IMPAIRMENT [recorded under section 93L(2) of the Act] Record No. | | | | Worker's details |Surname | |Other names | | | | | |Date of birth| |Sex | |Occupation | | | | | | | |Address | | | | | |Postcode | |Telephone no. | |WorkCover claim number| | | |(WCCN) | | | | | Employer's details |Name | | | | | |Address | | | | | |Postcode | |Telephone no. | |WorkCover number (WCN)| | | | | |Contact person | | | | | |Title | |Telephone no. | | | | | Insurer's details |Name | | | | | |Address | | | | | |Postcode | |Contact person | |Telephone no. | | | | | Injury details |Description of injury | | | |Date injury | | | |occurred | | | | | | | |Date the claim, if any, | |Claim number given by | |for compensation by way | |insurer (if known) | |of weekly payments was | | | |made on employer | | | | | | | Agreement |It has been agreed that the worker's degree of | |permanent whole of person impairment is - | |(a)|at least 15% | | |do not complete if "Yes" in|Yes |( | | |paragraph (b) | | | | | |No |( | |(b)|at least 25% | | |do not complete if "No" in |Yes |( | | |paragraph (a) | | | | | |No |( | Recorded | | |Signature| | | | | |of | |Date |/ | | |Director | | |/ | | | | | | | | Copies of record sent | | |To worker| | | | | | | |Date |/ | | | | | |/ | | | |(signature of person | | | | | |sending copy) | | | | |To | | | | | |employer | |Date |/ | | | | | |/ | | | |(signature of person | | | | | |sending copy) | | | | [Form 32 inserted in Gazette 28 Oct 2005 p. 4944-6.] Form 33 [r. 21] Workers' Compensation and Injury Management Act 1981 ASSESSMENT OF DEGREE OF PERMANENT WHOLE OF PERSON IMPAIRMENT [recorded under section 93L(2) of the Act] Record No. | | | | Worker's details |Surname | |Other names | | | | | |Date of birth| |Sex | |Occupation | | | | | | | |Address | | | | | |Postcode | |Telephone no. | |WorkCover claim number| | | |(WCCN) | | | | | Employer's details |Name | | | | | |Address | | | | | |Postcode | |Telephone no. | |WorkCover number (WCN)| | | | | |Contact person | | | | | |Title | |Telephone no. | | | | | Insurer's details |Name | | | | | |Address | | | | | |Postcode | |Contact person | |Telephone no. | | | | | Injury details |Description of injury | | | |Date injury | | | |occurred | | | | | | | |Date the claim, if any, | |Claim number given by | |for compensation by way | |insurer (if known) | |of weekly payments was | | | |made on employer | | | | | | | Assessment |Name of approved medical| | | |specialist assessing | | | | |Registrat| | | |ion | | | |number | | |Degree of permanent whole of| | |person impairment | | | % | | |Copy provided of - | |(a)|certificate given to the worker under |( | | |section 146H(1)(b) of the Act | | |(b)|certificate referred to in |( | | |section 93N(1) of the Act on the basis| | | |of which the special evaluation was | | | |requested (only required if the | | | |assessment involves a special | | | |evaluation as defined in | | | |section 146C(4) of the Act) | | Recorded | | |Signature| | | | | |of | |Date |/ | | |Director | | |/ | | | | | | | | Copies of record sent to | | |worker | | | | | | | |Date |/ | | | | | |/ | | | |(signature of person | | | | | |sending copy) | | | | |employer | | | | | | | |Date |/ | | | | | |/ | | | |(signature of person | | | | | |sending copy) | | | | [Form 33 inserted in Gazette 28 Oct 2005 p. 4946-8.] Form 34 [r. 22] Workers' Compensation and Injury Management Act 1981 ELECTION TO RETAIN RIGHT TO SEEK DAMAGES [made under section 93K(4) of the Act] Registration No. | | | | Worker's details |Surname | |Other names | | | | | |Date of birth| |Sex | |Occupation | | | | | | | |Address | | | | | |Postcode | |Telephone no. | |WorkCover claim number| | | |(WCCN) | | | | | | | |(if not known, insurer| | | |can provide WCCN) | Employer's details |Name | | | | | |Address | | | | | |Postcode | |Telephone no. | |WorkCover number (WCN)| | | | | |Contact person | | | | | |Title | |Telephone no. | | | | | Insurer's details |Name | | | | | |Address | | | | | |Postcode | |Contact person | |Telephone no. | | | | | Injury details |Description of injury | | | |Date injury | | | |occurred | | | | | | | |Date the claim, if any, | |Claim number given by | |for compensation by way | |insurer (if known) | |of weekly payments was | | | |made on employer | | | | | | | |Degree of permanent whole | | |of person impairment | | | % | | |The Director has, under section 93L of the Act, | |recorded an agreement or assessment as to the | |worker's degree of permanent whole of person | |impairment, and the Record Number is: | |Record Number | | Termination day |1. Did a dispute resolution authority, acting | |under section 58(1) or (2) of the Act, determine | |the question of liability to make the weekly | |payments claimed? | | |Yes |( |If so, answer question 2.| | |No |( |If not, skip question 2. | |2. Was the question determined more than 3 months | |after the day on which compensation by way of | |weekly payments was claimed? | | |Yes |( |If so, on | | | | | | |which date? | | | | |No | ( | | |3. Was the worker first notified that liability is| |accepted in respect of the weekly payments claimed| |more than 3 months after the day on which | |compensation by way of weekly payments was | |claimed? | | |Yes |( |If so, on | | | | | | |which date? | | | | |No |( | | |4. Has the termination day been extended under | |section 93M(4) of the Act? | | |Yes |( |If so, to | | | | | | |which date? | | | | |No | ( | | |WARNING | |An election cannot be withdrawn after the Director| |registers it and a subsequent election cannot be | |made in respect of the same injury or injuries | |(see section 93L(6) of the Act). | |Registration of an election may affect your | |entitlement to statutory compensation under the | |Workers' Compensation and Injury Management | |Act 1981. | |You should seek appropriate independent advice | |before lodging this form. | Advice of consequences of election |I have been properly advised of the consequences | |of making this election. | |Signature| | | | | |of worker| |Date |/ | | | | | |/ | | | | | | | | Registration of this election |This election form was lodged under regulation 22 | |and registered on the day shown below. | |Signature| | | | | |of | |Date |/ | | |Director | | |/ | | | | | | | | Copies of election form sent to | | |worker | | | | | | | |Date |/ | | | | | |/ | | | |(signature of person | | | | | |sending copy) | | | | |employer | | | | | | | |Date |/ | | | | | |/ | | | |(signature of person | | | | | |sending copy) | | | | [Form 34 inserted in Gazette 28 Oct 2005 p. 4948-50.] Form 35 [r. 23] Workers' Compensation and Injury Management Act 1981 APPLICATION TO EXTEND TERMINATION DAY [for extension under section 93M(4) of the Act] Worker's details |Surname | |Other names | | | | | |Date of birth| |Sex | |Occupation | | | | | | | |Address | | | | | |Postcode | |Telephone no. | |WorkCover claim number| | | |(WCCN) | | | | | | | |(if not known, insurer| | | |can provide WCCN) | Employer's details |Name | | | | | |Address | | | | | |Postcode | |Telephone no. | |WorkCover number (WCN)| | | | | |Contact person | | | | | |Title | |Telephone no. | | | | | Insurer's details |Name | | | | | |Address | | | | | |Postcode | |Contact person | |Telephone no. | | | | | Injury details |Description of injury | | | |Date injury | | | |occurred | | | | | | | |Date the claim for | |Claim number given by | |compensation by way of | |insurer (if known) | |weekly payments was made| | | |on employer | | | | | | | Termination day |1. Did a dispute resolution authority, acting | |under section 58(1) or (2) of the Act, determine | |the question of liability to make the weekly | |payments claimed? | | |Yes |( |If so, answer question 2.| | |No |( |If not, skip question 2. | |2. Was the question determined more than 3 months | |after the day on which compensation by way of | |weekly payments was claimed? | | |Yes |( |If so, on | | | | | | |which date? | | | | |No | ( | | |3. Was the worker first notified that liability is| |accepted in respect of the weekly payments claimed| |more than 3 months after the day on which | |compensation by way of weekly payments was | |claimed? | | |Yes |( |If so, on | | | | | | |which date? | | | | |No | ( | | |4. Has the termination day been extended under | |section 93M(4) of the Act? | | |Yes |( |If so, to | | | | | | |which date? | | | | |No | ( | | Extension sought |1. This application is for the termination day to | |be extended in the circumstances described in - | | |( |section 93M(4)(a|(worker's condition has not | | | |) of Act |stabilised) | | |( |section 93M(4)(b|(employer failed to comply | | | |) of Act |with section 93O of Act) | | |( |section 93M(4)(c|(more time required to give | | | |) of Act |documents to worker) | | |( |section 93M(4)(d|(assessment requested but | | | |)(i) of Act |documents not available | | | | |within specified time - not | | | | |special evaluation) | | |( |section 93M(4)(d|(assessment requested but | | | |)(ii) of Act |documents not available | | | | |within specified time - | | | | |special evaluation) | | | |2. Specify date until | | | | |which extension sought. | | | | | | |Signature| | | | | |of worker|_____________________|Date |/ | | | |___________ | |/ | | How to lodge this form |1. This form should be lodged with: | | |Director | | |WorkCover WA | | |Perth, WA | |2. WHEN LODGING THIS FORM ALSO PROVIDE ANYTHING | |ELSE THAT REGULATION 23 REQUIRES YOU TO PROVIDE. | Extension given or refused |The termination day | | |is | | / | | | |extended | |/ | | | |to | | | | | |is not |( | | | |extended. | | | |Signature| | | | | |of | |Date |/ | | |Director | | |/ | | | | | | | | Copies of extension sent to | | |worker | | | | | | | |Date |/ | | | | | |/ | | | |(signature of person | | | | | |sending copy) | | | | |employer | | | | | | | |Date |/ | | | | | |/ | | | |(signature of person | | | | | |sending copy) | | | | [Form 35 inserted in Gazette 28 Oct 2005 p. 4951-3; amended in Gazette 18 Nov 2011 p. 4825.] Form 36 [r. 25] Workers' Compensation and Injury Management Act 1981 NOTICE TO WORKER ABOUT TERMINATION DAY FOR ELECTION [under section 93O of the Act] Date on which notice given (insert date) (Insert name of worker) (Insert address of worker) WorkCover claim number (WCCN) (insert number) Date of injury (insert date) Date when claim for compensation made on employer: (insert date) IMPORTANT INFORMATION Section 93O of the Workers' Compensation and Injury Management Act 1981 entitles you to notice of certain things that may affect the damages you could recover in court. If your cause of action arises on or after 14 November 2005, a court will not be able to award damages for your injury if you do not elect under section 93K of the Act to retain the right to seek damages and have the election registered by WorkCover's Director. On the other hand, registering your election may affect your entitlement to statutory compensation. You should seek advice on whether or not to make an election. One rule about electing is that, if you claim compensation by way of weekly payments because of your injury, you cannot elect after the termination day (there are exceptions to this rule for AIDS and specified industrial diseases). Your termination day for this injury is .............. (specify date), which is about 6 months away. You may be able to apply for the termination day to be extended but an extension can only be given in limited circumstances (see section 93M(4) and (8) of the Act). Also, before you can elect, an agreement (between you and your employer) or assessment (by an approved medical specialist you select - see the register kept by the Director) about the level of your degree of permanent whole of person impairment has to be made and recorded by the Director. The level agreed or assessed has to be 15% or more. If you request an assessment, the approved medical specialist can reasonably be expected to take 6 weeks from when you make the request to give you the documents about the outcome of the assessment. In some cases 7 weeks is relevant (see section 93M(4)(d)(ii) of the Act). You need to allow for this time. This notice is a standard document and is not meant to be relied on instead of obtaining appropriate advice. Employer's details |Name | | | | | |Address | | | | | |Postcode | |Telephone no. | |WorkCover number (WCN)| | | | | |Contact person | | | | | |Title | |Telephone no. | | | | | [Form 36 inserted in Gazette 28 Oct 2005 p. 4953-4; amended in Gazette 18 Nov 2011 p. 4825.] Form 37 [r. 47(4)(a)] Workers' Compensation and Injury Management Act 1981 RECORD OF AGREEMENT ABOUT DEGREE OF PERMANENT WHOLE OF PERSON IMPAIRMENT [recorded under section 158B(1)(a)(i) of the Act] Record No. | | | | Worker's details |Surname | |Other names | | | | | |Date of birth| |Sex | |Occupation | | | | | | | |Address | | | | | |Postcode | |Telephone no. | |WorkCover claim number| | | |(WCCN) | | | | | Employer's details |Name | | | | | |Address | | | | | |Postcode | |Telephone no. | |WorkCover number (WCN)| | | | | |Contact person | | | | | |Title | |Telephone no. | | | | | Insurer's details |Name | | | | | |Address | | | | | |Postcode | |Contact person | |Telephone no. | | | | | Injury details |Description of injury | | | |Date injury | | | |occurred | | | | | | | |Date the claim, if any, | |Claim number given by | |for compensation by way | |insurer (if known) | |of weekly payments was | | | |made on employer | | | | | | | Agreement |It has been agreed that the worker's degree of | |permanent whole of person impairment is - | |(a)|at least 10% | | |do not complete if "No" in |Yes |( | | |paragraph (b) | | | | | |No |( | |(b)|less than 15% | | |do not complete if "No" in |Yes |( | | |paragraph (a) | | | | | |No |( | Recorded | | |Signature| | | | | |of | |Date |/ | | |Director | | |/ | | | | | | | | Copies of record sent | | |To worker| | | | | | | |Date |/ | | | | | |/ | | | |(signature of person | | | | | |sending copy) | | | | |To | | | | | |employer | |Date |/ | | | | | |/ | | | |(signature of person | | | | | |sending copy) | | | | [Form 37 inserted in Gazette 28 Oct 2005 p. 4955-6.] Form 38 [r. 47(4)(b)] Workers' Compensation and Injury Management Act 1981 RECORD OF AGREEMENT ABOUT RETRAINING CRITERIA [recorded under section 158B(1)(b)(i) of the Act] Record No. | | | | Worker's details |Surname | |Other names | | | | | |Date of birth| |Sex | |Occupation | | | | | | | |Address | | | | | |Postcode | |Telephone no. | |WorkCover claim number| | | |(WCCN) | | | | | Employer's details |Name | | | | | |Address | | | | | |Postcode | |Telephone no. | |WorkCover number (WCN)| | | | | |Contact person | | | | | |Title | |Telephone no. | | | | | Insurer's details |Name | | | | | |Address | | | | | |Postcode | |Contact person | |Telephone no. | | | | | Injury details |Description of injury | | | |Date injury | | | |occurred | | | | | | | |Date the claim, if any, | |Claim number given by | |for compensation by way | |insurer (if known) | |of weekly payments was | | | |made on employer | | | | | | | Agreement |It has been agreed that the worker satisfies all | |of the retraining criteria defined in | |section 158(1) of the Act. | Recorded | | |Signature| | | | | |of | |Date |/ | | |Director | | |/ | | | | | | | | Copies of record sent | | |To worker| | | | | | | |Date |/ | | | | | |/ | | | |(signature of person | | | | | |sending copy) | | | | |To | | | | | |employer | |Date |/ | | | | | |/ | | | |(signature of person | | | | | |sending copy) | | | | [Form 38 inserted in Gazette 28 Oct 2005 p. 4957-8.] Form 39 [r. 48] Workers' Compensation and Injury Management Act 1981 APPLICATION TO EXTEND FINAL DAY [for extension under section 158B(4) of the Act] Worker's details |Surname | |Other names | | | | | |Date of birth| |Sex | |Occupation | | | | | | | |Address | | | | | |Postcode | |Telephone no. | |WorkCover claim number| | | |(WCCN) | | | | | | | |(if not known, insurer| | | |can provide WCCN) | Employer's details |Name | | | | | |Address | | | | | |Postcode | |Telephone no. | |WorkCover number (WCN)| | | | | |Contact person | | | | | |Title | |Telephone no. | | | | | Insurer's details |Name | | | | | |Address | | | | | |Postcode | |Contact person | |Telephone no. | | | | | Injury details |Description of injury | | | |Date injury | | | |occurred | | | | | | | |Date the claim for | |Claim number given by | |compensation by way of | |insurer (if known) | |weekly payments was made| | | |on employer | | | | | | | Final day under section 158B of the Act |1. Did a dispute resolution authority, acting | |under section 58(1) or (2) of the Act, determine | |the question of liability to make the weekly | |payments claimed? | | |Yes |( |If so, answer question 2.| | |No |( |If not, skip question 2. | |2. Was the question determined more than 3 months | |after the day on which compensation by way of | |weekly payments was claimed? | | |Yes |( |If so, on | | | | | | |which date? | | | | |No | ( | | |3. Was the worker first notified that liability is| |accepted in respect of the weekly payments claimed| |more than 3 months after the day on which | |compensation by way of weekly payments was | |claimed? | | |Yes |( |If so, on | | | | | | |which date? | | | | |No | ( | | |4. Has the final day been extended under | |section 158B(4) of the Act? | | |Yes |( |If so, to | | | | | | |which date? | | | | |No | ( | | Extension sought |1. This application is for the final day to be | |extended under section 158B(4) of the Act. | | | |2. Specify date until | | | | |which extension sought. | | | | | | |Signature| | | | | |of worker| |Date |/ | | | | | |/ | | | | | | | | How to lodge this form |1. This form should be lodged with: | | |Director | | |WorkCover WA | | |Perth, WA | |2. WHEN LODGING THIS FORM ALSO PROVIDE ANYTHING | |ELSE THAT REGULATION 48 REQUIRES YOU TO PROVIDE. | Extension given or refused |The final day | | |is | | / | | | |extended | |/ | | | |to | | | | | |is not |( | | | |extended. | | | |Signature| | | | | |of | |Date |/ | | |Director | | |/ | | | | | | | | Copies of extension sent to | | |worker | | | | | | | |Date |/ | | | | | |/ | | | |(signature of person | | | | | |sending copy) | | | | |employer | | | | | | | |Date |/ | | | | | |/ | | | |(signature of person | | | | | |sending copy) | | | | [Form 39 inserted in Gazette 28 Oct 2005 p. 4959-61; amended in Gazette 18 Nov 2011 p. 4825.] Form 40 [r. 52] Workers' Compensation and Injury Management Act 1981 Infringement notice Serial No. ............... Date ......../......./....... |To: (1) | |of: (2) | |It is alleged that on ......../......../........ | |at or about (3) | |at (4) | |the alleged offender named above committed the | |following offence - | | | | | | | |contrary to section (5) | |................................ of the Workers' | |Compensation and Injury Management Act 1981. | |The modified penalty for this offence is $ . | |If the alleged offender wishes to be prosecuted | |for the alleged offence in a court, the modified | |penalty should not be paid and no reply to this | |notice is required. The alleged offender may | |become liable to pay a fine and costs if court | |proceedings are taken against the alleged | |offender. | |If the alleged offender does not wish to be | |prosecuted for the alleged offence in a court, the| |amount of the modified penalty may be paid within | |the period of 28 days after the giving of this | |notice. Payment may be made by either - | |posting this form and a cheque or money order, | |made payable to WorkCover Western Australia, for | |the amount of the modified penalty to the Chief | |Executive Officer, WorkCover WA, 2 Bedbrook Place,| |Shenton Park WA 6008; or | |delivering this form, and paying the amount of the| |modified penalty to an authorised officer*, at | |WorkCover WA, 2 Bedbrook Place, Shenton Park WA | |6008. | |Name and title of authorised officer giving the | |notice: | | | |Signature: | |..................................................| |.. | |*The following are authorised officers for the | |purposes of receiving payment of modified | |penalties: | | | (1) Name of alleged offender (2) Address of alleged offender (3) Time when offence allegedly committed (4) Place where offence allegedly committed (5) Section designation [Form 40 inserted in Gazette 28 Oct 2005 p. 4962-3.] Form 41 [r. 53] Workers' Compensation and Injury Management Act 1981 Withdrawal of infringement notice Serial No. ............... Date ......../......./....... |To: (1) | |of: (2) | |Infringement notice No. | |..............................................date| |d ......../......../........ for the alleged | |offence of . | | | |contrary to section .................... of the | |Workers' Compensation and Injury Management | |Act 1981 has been withdrawn. | |The modified penalty of $ ........................| | | |* has been paid and a refund is enclosed. | |* has not been paid and should not be paid. | |* Delete as appropriate | |Name and title of authorised officer giving this | |notice: | | | |Signature | (1) Name of alleged offender given the infringement notice (2) Address of alleged offender [Form 41 inserted in Gazette 28 Oct 2005 p. 4963.] Appendix II [r. 9] [Heading deleted in Gazette 21 Jan 2005 p. 277.] Table showing present values of $1.00 per annum payable weekly assuming an effective earning rate of 3% per annum Weeks |Years | |Frequency Right Left Better Worse PLH | |Ear Ear Ear Ear | |500 40 10 10 40 1.7 | |1000 45 25 25 45 4.2 | |1500 50 40 40 50 7.1 | |2000 55 55 55 55 8.4 | |3000 60 70 60 70 6.5 | |4000 65 85 65 85 7.1 | |Overall Binaural PLH = 35.0% | Table RB - 500 Values of percentage loss of hearing corresponding to given hearing threshold levels in the better and worse ears at 500 Hz HTL - BETTER EAR | | |Frequency|Right |Left |Better |Worse |PLH | | |Ear |Ear |Ear |Ear | | |500 |40 |10 |10 |40 |1.7 | |1000 |45 |25 |25 |45 |4.2 | |1500 |50 |40 |40 |50 |7.1 | |2000 |55 |55 |55 |55 |8.4 | |3000 |60 |70 |60 |70 |6.5 | |4000 |65 |85 |65 |85 |4.3 | |6000 |55 |75 |55 |75 |1.7 | |8000 |45 |65 |45 |65 |0.4 | |Overall Binaural PLH = 34.3% | Table EB - 8000 Values of percentage loss of hearing corresponding to given hearing threshold levels in the better and worse ears at 8000 Hz HTL - BETTER EAR | |(30 |35 |40 | |1A. |57A(2A) |Failing to claim under policy| | | | |of insurance |$200.00 | |1. |57A(3) |Failing to provide notice |$200.00 | |2. |57A(4) |Failing to cause notification| | | | |to be accompanied by means | | | | |for conveying information in |$200.00 | | | |machine-readable form | | |3A. |57A(8A) |Failing to make weekly |$400.00 | | | |payment | | |3B. |57A(8) |Failing to make weekly | | | | |payment having received |$400.00 | | | |payment from insurer | | |3. |57B(2) |Failing to make first weekly | | | | |payment or give notice |$200.00 | |4. |57B(2b) |Failing to notify WorkCover | | | | |WA of having declined to |$200.00 | | | |indemnify employer | | |5. |57B(3) |Failing to cause notification| | | | |to be accompanied by means | | | | |for conveying information in |$200.00 | | | |machine-readable form | | |6A. |57B(8) |Failing to make weekly |$400.00 | | | |payment | | |6. |57C(2) |Failing to notify WorkCover | | | | |WA after weekly payments |$200.00 | | | |commenced | | |7. |57C(4) |Failing to notify WorkCover | | | | |WA of discontinuance of |$200.00 | | | |weekly payments | | |8. |61(2a)(a|Failing to give notice of | | | |) |intention to discontinue or |$400.00 | | | |reduce weekly payments | | |9. |61(2a)(b|Failing to give notice that | | | |) |complies with section 61(2) |$400.00 | | | |of the Act | | |10. |70(2) |Failing to furnish worker | | | | |with copy of report |$400.00 | |11. |75(2) |Giving notice contrary to | | | | |section 75(1) of the Act |$200.00 | |12. |103A(2) |Furnishing WorkCover WA with | | | | |false information or return |$400.00 | |13. |109(3) |Failing to pay contribution |$400.00 | | | |or instalment | | |14. |109(4b) |Failing to send particulars | | | | |to WorkCover WA |$400.00 | |15. |109(6) |Failing to send return or | | | | |statutory declaration to |$400.00 | | | |WorkCover WA | | |16. |152 |Charging a premium rate | | | | |loading of more than 75% |$200.00 | | | |without permission | | |17. |155D(3) |Failing to take reasonable | | | | |action to discharge and | | | | |comply with employer's |$400.00 | | | |obligations | | |18. |160(3) |Failing to insure employer | | | | |for full amount of liability |$400.00 | | | |to pay compensation | | |19. |160(3a) |Failing to notify employer of| | | | |cancellation of insurance |$200.00 | |20. |160(5) |Declining to indemnify |$400.00 | | | |employer | | |21. |162(1a) |Issuing or renewing policy in| | | | |respect of certain industrial|$200.00 | | | |diseases | | |22. |165(5) |Failing to give securities to| | | | |State as directed by Minister|$200.00 | |23. |171(1) |Failing to transmit to | | | | |WorkCover WA statements and | | | | |means for conveying |$200.00 | | | |information in | | | | |machine-readable form | | |24. |180(5) |Failing to comply with | | | | |request to provide copy of |$200.00 | | | |relevant document | | [Appendix V inserted in Gazette 28 Oct 2005 p. 4970-2; amended in Gazette 18 Nov 2011 p. 4826.] Notes 1 This is a compilation of the Workers' Compensation and Injury Management Regulations 1982 and includes the amendments made by the other written laws referred to in the following table. The table also contains information about any reprint. Compilation table |Citation |Gazettal |Commencement | |Workers' Compensation |8 Apr 198|3 May 1982 (see r. 2| |and Assistance |2 |and Gazette | |Regulations 1982 4 |p. 1229-5|8 Apr 1982 p. 1205) | | |0 | | | |(corrigen| | | |dum | | | |23 Apr 19| | | |82 | | | |p. 1384) | | |Workers' Compensation |14 May 19|14 May 1982 | |and Assistance |82 | | |Amendment |p. 1519 | | |Regulations 1982 | | | |Workers' Compensation |27 Aug 19|27 Aug 1982 | |and Assistance |82 | | |Amendment Regulations |p. 3427-9| | |(No. 2) 1982 | | | |Workers' Compensation |30 Dec 19|30 Dec 1983 | |and Assistance |83 | | |Amendment |p. 5121 | | |Regulations 1983 | | | |Workers' Compensation |25 Jul 19|25 Jul 1986 (see | |and Assistance |86 |r. 2 and Gazette | |Amendment |p. 2484-5|25 Jul 1986 p. 2453)| |Regulations 1986 | | | |Workers' Compensation |22 May 19|22 May 1987 (see | |and Assistance |87 |r. 2 and Gazette | |Amendment |p. 2193 |22 May 1987 p. 2167)| |Regulations 1987 | | | |Workers' Compensation |19 Jun 19|1 Jul 1987 (see | |and Assistance |87 |r. 2) | |Amendment Regulations |p. 2410 | | |(No. 2) 1987 | | | |Workers' Compensation |2 Sep 198|2 Sep 1988 | |and Assistance |8 p. 3464| | |Amendment | | | |Regulations 1988 | | | |Workers' Compensation |22 Sep 19|22 Sep 1989 | |and Assistance |89 | | |Amendment Regulations |p. 3490-1| | |(No. 2) 1989 | | | |Workers' Compensation |26 Feb 19|1 Mar 1991 (see r. 2| |and Assistance |91 |and Gazette | |Amendment |p. 931-56|1 Mar 1991 p. 967) | |Regulations 1991 | | | |Workers' Compensation |8 Mar 199|8 Mar 1991 (see r. 2| |and Assistance |1 |and Gazette | |Amendment Regulations |p. 1071-6|8 Mar 1991 p. 1030) | |(No. 2) 1991 | | | |Workers' Compensation |28 Jun 19|1 Jul 1991 (see | |and Rehabilitation |91 |r. 2) | |Amendment Regulations |p. 3291-4| | |(No. 3) 1991 | | | |Workers' Compensation |6 Dec 199|6 Dec 1991 | |and Rehabilitation |1 | | |Amendment Regulations |p. 6118-1| | |(No. 4) 1991 |9 | | |Workers' Compensation |3 Apr 199|3 Apr 1992 | |and Rehabilitation |2 | | |Amendment Regulations |p. 1540-1| | |(No. 2) 1992 | | | |Workers' Compensation |3 Apr 199|3 Apr 1992 | |and Rehabilitation |2 | | |Amendment |p. 1541-5| | |Regulations 1992 | | | |Reprint of the Workers' Compensation and | |Rehabilitation Regulations 1982 as at 30 Apr 1992 | |(includes amendments listed above) | |Workers' Compensation |16 Oct 19|16 Oct 1992 | |and Rehabilitation |92 | | |Amendment Regulations |p. 5201 | | |(No. 4) 1992 | | | |Workers' Compensation |5 Feb 199|5 Feb 1993 (see r. 2| |and Rehabilitation |3 |and Gazette | |Amendment |p. 1059-6|5 Feb 1993 p. 975) | |Regulations 1993 |0 | | |Workers' Compensation |17 Sep 19|17 Sep 1993 | |and Rehabilitation |93 | | |Amendment Regulations |p. 5182 | | |(No. 3) 1993 | | | |Workers' Compensation |29 Oct 19|29 Oct 1993 | |and Rehabilitation |93 | | |Amendment Regulations |p. 5929-3| | |(No. 2) 1993 |0 | | |Workers' Compensation |24 Dec 19|24 Dec 1993 (see | |and Rehabilitation |93 |r. 2 and Gazette | |Amendment Regulations |p. 6844-5|24 Dec 1993 p. 6795)| |(No. 4) 1993 |0 | | |Workers' Compensation |18 Feb 19|1 Mar 1994 (see | |and Rehabilitation |94 |r. 2) | |Amendment |p. 660-4 | | |Regulations 1994 | | | |Workers' Compensation |31 Mar 19|31 Mar 1994 | |and Rehabilitation |94 | | |Amendment Regulations |p. 1444 | | |(No. 2) 1994 | | | |Workers' Compensation |24 Jun 19|24 Jun 1994 | |and Rehabilitation |94 | | |Amendment Regulations |p. 2888-9| | |(No. 3) 1994 | | | |Workers' Compensation |23 Aug 19|23 Aug 1994 | |and Rehabilitation |94 | | |Amendment Regulations |p. 4394-5| | |(No. 4) 1994 | | | |Reprint of the Workers' Compensation and | |Rehabilitation Regulations 1982 as at 14 Feb 1995 | |(includes amendments listed above) | |Workers' Compensation |25 Aug 19|25 Aug 1995 | |and Rehabilitation |95 | | |Amendment |p. 3885-7| | |Regulations 1995 | | | |Workers' Compensation |15 Sep 19|15 Sep 1995 | |and Rehabilitation |95 | | |Amendment |p. 4358 | | |Regulations (No. 2) | | | |1995 | | | |Workers' Compensation |17 Jan 19|17 Jan 1997 | |and Rehabilitation |97 p. 444| | |Amendment | | | |Regulations 1996 | | | |Workers' Compensation |12 Aug 19|12 Aug 1997 | |and Rehabilitation |97 | | |Amendment |p. 4568 | | |Regulations 1997 | | | |Workers' Compensation |12 Jun 19|1 Jul 1998 (see | |and Rehabilitation |98 |r. 2) | |Amendment |p. 3205 | | |Regulations 1998 | | | |Workers' Compensation |13 Apr 19|3 May 1999 | |and Rehabilitation |99 |(see r. 2) | |Amendment |p. 1529-4| | |Regulations 1999 |1 | | | |(correcti| | | |on | | | |16 Apr 19| | | |99 | | | |p. 1598) | | |Workers' Compensation |22 Jun 19|1 Jul 1999 | |and Rehabilitation |99 |(see r. 2) | |Amendment Regulations |p. 2692-3| | |(No. 3) 1999 | | | |Workers' Compensation |15 Oct 19|15 Oct 1999 | |and Rehabilitation |99 |(see r. 2) | |Amendment |p. 4890-8| | |Regulations (No. 4) | | | |1999 | | | |Workers' Compensation |15 Oct 19|15 Oct 1999 (see | |and Rehabilitation |99 |r. 2 and Gazette | |Amendment |p. 4899 |15 Oct 1999 p. 4889)| |Regulations (No. 5) | | | |1999 | | | |Workers' Compensation |15 Oct 19|15 Oct 1999 | |and Rehabilitation |99 |(see r. 2 and | |Amendment |p. 4900-2|Gazette 15 Oct 1999 | |Regulations (No. 6) | |p. 4889) | |1999 | | | |Workers' Compensation |15 Oct 19|15 Oct 1999 | |and Rehabilitation |99 |(see r. 2 and | |Amendment |p. 4903 |Gazette 15 Oct 1999 | |Regulations (No. 7) | |p. 4889) | |1999 | | | |Workers' Compensation |15 Oct 19|15 Oct 1999 | |and Rehabilitation |99 |(see r. 2 and | |Amendment |p. 4904 |Gazette 15 Oct 1999 | |Regulations (No. 8) | |p. 4889) | |1999 | | | |Workers' Compensation |15 Oct 19|15 Oct 1999 | |and Rehabilitation |99 |(see r. 2 and | |Amendment |p. 4905 |Gazette 15 Oct 1999 | |Regulations (No. 9) | |p. 4889) | |1999 | | | |Workers' Compensation |15 Oct 19|15 Oct 1999 | |and Rehabilitation |99 |(see r. 2) | |Amendment |p. 4906-1| | |Regulations (No. 10) |2 | | |1999 | | | |Workers' Compensation |14 Dec 19|14 Dec 1999 | |and Rehabilitation |99 | | |Amendment |p. 6145-6| | |Regulations (No. 11) |3 | | |1999 | | | |Reprint of the Workers' Compensation and | |Rehabilitation Regulations 1982 as at 25 Feb 2000 | |(includes amendments listed above) | |Workers' Compensation |17 Nov 20|17 Nov 2000 | |and Rehabilitation |00 | | |Amendment |p. 6307-2| | |Regulations 2000 |2 | | |Corporations |28 Sep 20|15 Jul 2001 | |(Consequential |01 |(see r. 2 and Cwlth | |Amendments) |p. 5353-8|Gazette 13 Jul 2001 | |Regulations 2001 Pt. 7 | |No. S285) | |Workers' Compensation |8 Mar 200|8 Mar 2002 | |and Rehabilitation |2 | | |Amendment |p. 948-9 | | |Regulations 2002 | | | |Reprint 4: The Workers' Compensation and | |Rehabilitation Regulations 1982 as at 17 Apr 2003 | |(includes amendments listed above) | |Equality of Status |30 Jun 20|1 Jul 2003 (see r. 2| |Subsidiary Legislation |03 |and Gazette | |Amendment |p. 2581-6|30 Jun 2003 p. 2579)| |Regulations 2003 Pt. 42|38 | | |Workers' Compensation |16 Sep 20|16 Sep 2003 | |and Rehabilitation |03 | | |Amendment |p. 4103-4| | |Regulations 2003 | | | |Workers' Compensation |8 Apr 200|8 Apr 2004 | |and Rehabilitation |4 p. 1177| | |Amendment | | | |Regulations 2004 | | | |Workers' Compensation |26 Oct 20|26 Oct 2004 (see | |and Rehabilitation |04 |r. 2) | |Amendment Regulations |p. 4895-9| | |(No. 2) 2004 |13 | | |Workers' Compensation |29 Oct 20|29 Oct 2004 | |and Rehabilitation |04 | | |Amendment Regulations |p. 4939-4| | |(No. 3) 2004 |0 | | |Workers' Compensation |21 Jan 20|21 Jan 2005 | |and Rehabilitation |05 | | |Amendment |p. 275-7 | | |Regulations 2005 | | | |Workers' Compensation |28 Oct 20|14 Nov 2005 (see | |and Injury Management |05 |r. 2) | |Amendment |p. 4853-9| | |Regulations (No. 2) |72 | | |2005 | | | |Workers' Compensation |9 Dec 200|9 Dec 2005 | |and Injury Management |5 | | |Amendment |p. 5891-7| | |Regulations (No. 3) | | | |2005 | | | |Reprint 5: The Workers' Compensation and Injury | |Management Regulations 1982 as at 3 Feb 2006 (includes| |amendments listed above) | |Workers' Compensation |4 Aug 200|4 Aug 2006 | |and Injury Management |6 | | |Amendment |p. 2855-6| | |Regulations 2006 | | | |Workers' Compensation |15 Dec 20|15 Dec 2006 | |and Injury Management |06 | | |Amendment |p. 5636-7| | |Regulations (No. 2) | | | |2006 | | | |Workers' Compensation |2 Nov 200|r. 1 and 2: | |and Injury Management |7 |2 Nov 2007 | |Amendment |p. 5933-4|(see r. 2(a)); | |Regulations 2007 | |Regulations other | | | |than r. 1 and 2: | | | |3 Nov 2007 (see | | | |r. 2(b)) | |Workers' Compensation |17 Dec 20|r. 1 and 2: | |and Injury Management |08 |17 Dec 2008 | |Amendment |p. 5331-4|(see r. 2(a)); | |Regulations 2008 | |Regulations other | | | |than r. 1 and 2: | | | |18 Dec 2008 (see | | | |r. 2(b)) | |Reprint 6: The Workers' Compensation and Injury | |Management Regulations 1982 as at 14 Aug 2009 | |(includes amendments listed above) | |Workers' Compensation |19 Mar 20|r. 1 and 2: | |and Injury Management |10 |19 Mar 2010 | |Amendment |p. 1038-9|(see r. 2(a)); | |Regulations 2010 | |Regulations other | | | |than r. 1 and 2: | | | |20 Mar 2010 (see | | | |r. 2(b)) | |Workers' Compensation |10 Sep 20|r. 1 and 2: | |and Injury Management |10 |10 Sep 2010 | |Amendment Regulations |p. 4351-7|(see r. 2(a)); | |(No. 2) 2010 | |Regulations other | | | |than r. 1 and 2: | | | |1 Oct 2010 (see | | | |r. 2(b)) | |Workers' Compensation |18 Nov 20|r. 1 and 2: | |and Injury Management |11 |18 Nov 2011 | |Amendment Regulations |p. 4819-2|(see r. 2(a)); | |2011 |6 |Regulations other | | | |than r. 1 and 2: | | | |1 Dec 2011 (see | | | |r. 2(b) and Gazette | | | |8 Nov 2011 p. 4673) | 2 Formerly referred to the Workers' Compensation and Assistance Act 1981 the short title of which was changed to the Workers' Compensation and Rehabilitation Act 1981 by the Workers' Compensation and Assistance Amendment Act 1990 s. 5 and then to the Workers' Compensation and Injury Management Act 1981 by the Workers' Compensation Reform Act 2004 s. 5. The reference was changed under the Reprints Act 1984 s. 7(3)(gb). 3 The Standards Association of Australia has changed its corporate status and its name. It is now Standards Australia International Limited (ACN 087 326 690). It also trades as Standards Australia. 4 Now known as the Workers' Compensation and Injury Management Regulations 1982; citation changed (see note under r. 1). Defined Terms [This is a list of terms defined and the provisions where they are defined. The list is not part of the law.] Defined Term Provision(s) action level 19I(2) actual total cost 13(3) agent service 18B applicant 18B, 26 application 18B approved 19A approved medical practitioner 19A approved person 19A audiologist 19A audiometric officer 19A Australian Standard 19A clause 19A code of conduct 26 commencement day 18B, 43(4) counselling psychologist 44A(1) criminal record check 28(6) dispute resolution authority 18B dispute resolution body 43(4) employer 26 estimated total cost 13(3) exercise physiologist 44B(1) extension period 19N(1) fit and proper person 26 former provisions 18B independent agent 26 Insurer/Self-Insurer Electronic Data Specification (Edition Q1) 13(3) L peak 19I(2) legal service 18B March CPI 17AA(2), 17AE(2), 17A(2) MBS item 17AB(3) pending application 18LA(1) pending proceeding 43(4) prescribed details 18L registered Australian body 3(2) registration 26 relevant provisions of the Act 18L representative LAeq,8h 19I(2) representatives 11(2) taxing officer 18B termination day 19N(1) the relevant year 2A(1) treating specialist 17AB(3)