Western Australian Consolidated Regulations

WORKERS' COMPENSATION AND INJURY MANAGEMENT REGULATIONS 1982 - NOTES

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 Other Names Address ........................ Postcode Phone No. (H) .................... (W) Occupation (e.g. boiler maker, underground miner) Main tasks or duties performed (e.g. welding, drilling)		Date of Birth / /		Age		Sex M/F
		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)

EMPLOYER DETAILS — (Employer to complete)		WorkCover No. ..........
Trading name of employer (e.g. Browns Welding; E.J. Drilling Service)		Local Gov.
		Insurance Co.
Address of worker’s usual workplace or base		Policy No.

Name of Policy Holder ______________________________________________ Address Suburb/Town Post Code		Claim No: Insurer/self insurer to complete
		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 Other Names Address Postcode Phone No. (H) (W) Occupation (e.g. boiler maker, underground miner) Main tasks or duties performed (e.g. welding, drilling)		Date of Birth / /		Age		Sex M/F
		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)

EMPLOYER DETAILS — (Employer to complete)		WorkCover No. ......
Trading name of employer (e.g. Browns Welding; E.J. Drilling Service)		Local Gov.
		Insurance Co.
Address of worker’s usual workplace or base		Policy No.

Name of Policy Holder ______________________________________ Address Suburb/Town Post Code		Claim No: Insurer/self insurer to complete
		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 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 Applicant	Surname		Other Names
	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 deceased worker	Surname					Other Names
Sex		Male		Female		Date of 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 workplace or base	Postcode Telephone No.

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 Dependant	Date of Birth	Residential Address	Occupation	Relationship to deceased worker	Dependency Wholly Part ✓ Tick Box
					♦ ♦
					♦ ♦
					♦ ♦

Details of Fatality

Was the death the result of a		Yes		No
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 of personal injury, when did it occur?	Day of the week					Time			Date
									/ /
Date of death if different.		Date		/ /

Where did the injury occur? (e.g. Workshop floor, Hay Street, Cloverdale)

In the case of a disease, what was the date of death?

Date

/ /

Date of diagnosis

Date

/ /

If known, when was the deceased first incapacitated by the disease?

Date

/ /

Don’t know

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).

Have you attached a copy of any official notice of the deceased’s death?

YES

NO

YES

NO

If yes, please attach as much information as you can

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.
Signature		Date	/ /
Signature		Date	/ /

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 insurer/self‑insurer:		Date stamp of insurer/self‑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 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 duties, no further treatment required

❒ First and Final certificate [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 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.

Other restrictions:

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: ...........................................................................Date 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 occurred		Claim number given by 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/Cover Note No.	New (N) Renewal (R)	Name	Address	Occupation	Effective Date (If Less Than 12 Months Cover)	Expiry Date

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

GIVEN NAMES (in full) SEX

SURNAME

M

F

ADDRESS NUMBER AND STREET

SUBURB OR TOWN POSTCODE

DATE OF BIRTH

DAY MONTH YEAR

HOME PHONE NUMBER

WORK PHONE NUMBER

OCCUPATION OF WORKER

A.S.I.C. OFFICE USE

EMPLOYED BY:

FULL NAME OF EMPLOYER

ADDRESS NUMBER AND STREET OF EMPLOYER

SUBURB OR TOWN POSTCODE

PREDOMINANT INDUSTRY OF EMPLOYER

A.S.I.C. OFFICE USE

LEVEL OF TEST:

PURPOSE OF TEST:

Air‑conduction

Baseline

Full audiological

Medical Panel

WAUGH AND MACRAE’S CRITERIA:
(Please tick only if worker fails)

Item 1

Item 2

Item 3

HEARING TEST RESULTS

HERTZ (Hz)

500

1000

1500

2000

3000

4000

6000

8000

RT EAR

RT EAR **MASKED

AIR

CONDUCTION

LT EAR

LT EAR **MASKED

RT EAR

RT EAR MASKED

**BONE

CONDUCTION

LT EAR

LT EAR MASKED

CALCULATED PLH						%
	OFFICE USE

PERSON CONDUCTING TEST

SURNAME INITIAL REG. NO.

EQUIPMENT REG. NO.

BOOTH REG. NO.

I hereby certify, that I have personally conducted an audiometric test in accordance with the Workers’ Compensation and Injury Management Act 1981 and to the best of my knowledge and belief the results are true and correct.

		DATE OF 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

GIVEN NAMES (in full) SEX

SURNAME

M

F

FORMER SURNAME IF APPLICABLE

ADDRESS NUMBER AND STREET

SUBURB OR TOWN POSTCODE

DATE OF BIRTH

DAY MONTH YEAR

HOME PHONE NUMBER

WORK PHONE NUMBER

OCCUPATION OF WORKER

A.S.I.C. OFFICE USE

EMPLOYED OR FORMERLY EMPLOYED BY:

FULL NAME OF EMPLOYER

ADDRESS NUMBER AND STREET OF EMPLOYER

SUBURB OR TOWN POSTCODE

PREDOMINANT INDUSTRY OF EMPLOYER

A.S.I.C. OFFICE USE

LEVEL OF TEST:

PURPOSE OF TEST:

Air‑conduction

Full audiological

Subsequent

Medical Panel

Retired/Turning 65