Workers’ Compensation and Injury Management Act 1981

Workers’ Compensation and Injury Management Regulations 1982

 

Workers’ Compensation and Injury Management Regulations 1982

Contents

Part 1 — Preliminary

1.Citation1

2.Commencement1

2AAA.Terms used1

2AA.Notes not part of regulations2

Part 2 — General

2A.Indexation of redemption amount3

3.Certain registered bodies specified for definition of company (Act s. 5(1))3

3A.Instruments under Commonwealth laws prescribed for definition of industrial award in Act4

4A.Certain mines, mining operations prescribed for definition of mine or mining operation in Act4

4.Form of election4

5.Determination form for medical panel5

6AA.Form of claim for compensation5

6AB.Relevant document (Act s. 180(1)(j))5

6A.Form of first certificate of capacity5

6B.Form for insurer accepting liability6

6C.Form for insurer disputing liability6

6D.Form for insurer undecided on liability6

6E.Form for employer disputing liability6

6F.Form for employer undecided on liability6

6G.Giving notices under Act s. 57A and s. 57B and r. 257

7.Discontinuance or reduction of weekly payments7

7A.Form of progress certificate of capacity8

8.Frequency and time of medical examinations (Act s. 66)8

9.Compound discount table9

9A.Discount formula9

10.Worker not residing in State10

11.Payments after death outside State11

11A.Amount to discharge liability for child’s allowance (Act s. 72J(5))12

12.Agreements12

12AA.Notice of intention to dismiss worker (Act s. 84AB)14

12A.Contributions to General Account14

13.Ascertaining amount for reimbursement (Act s. 154AC(1))15

13A.Prescribed rate of interest (Act s. 222(2), 223(2) and 224(2))16

14.Insurance requirement (Act s. 160(1))16

15.Statements by approved insurance offices18

16A.Clause 1C notifications and elections (Act Sch. 1 cl. 1C, Sch. 8 cl. 10)18

17.Prescribed allowance (Act Sch. 1 cl. 11(2))19

17AA.Prescribed rate for vehicle running expenses (Act Sch. 1 cl. 19(1))20

17AB.Exceptional circumstances (Act Sch. 1 cl. 18A(2aa)(c)(ii))20

17AC.Management plan (Act Sch. 1 cl. 18A(2ac))21

17AD.Extending final day21

17AE.Amount prescribed for funeral expenses (Act Sch. 1 cl. 17(2), Sch. 8 cl. 10(1))22

17AF.Amount prescribed for child’s allowance (Act Sch. 1A cl. 5(b))23

17AG.Amount prescribed for funeral expenses (Act Sch. 1A cl. 9(2)(b))24

17A.Supplementary amount25

17B.Witness allowances25

18.Form of election to receive redemption amount or supplementary amount26

Part 2A  Assessment of costs

18A.Application of this Part27

18B.Terms used27

18C.Application for assessment of costs28

18D.Taxing officer may require application to be given to other persons28

18E.Taxing officer may require documents or further particulars29

18F.Consideration of application29

18G.Assessment to give effect to order and costs determination30

18H.Matters to be considered30

18I.Cost of assessment31

18J.Enforcement of assessment31

18K.Correction of error31

18LA.Transitional provision32

Part 2B  Medical assessment

18L.Terms used33

18M.Request for assessment by approved medical specialist of worker’s degree of impairment34

18N.Requirement to attend at place specified by approved medical specialist34

18O.Requirement to produce to approved medical specialist relevant documents and information and give consent35

18P.Period for compliance with requirements36

18Q.Requirement for worker to produce requested information36

18R.Reports and certificates regarding outcome of assessment37

18S.Requirement to attend at place specified by approved medical specialist panel38

18T.Requirement to produce to approved medical specialist panel relevant documents and information and give consent38

18U.Period for compliance with requirements39

18V.Requirement for worker to produce requested information39

18W.Reports and certificates regarding outcome of assessment40

Part 3 — Noise induced hearing loss

19A.Terms used41

19B.Persons approved to carry out audiometric testing41

19C.Testing procedures42

19D.Notice of audiometric test and testing arrangements46

19E.Calculation of loss of hearing46

19F.Report on audiometric test and storage of results46

19H.Retest of person’s hearing47

19I.Prescribed workplaces48

Part 3A — Constraints on awards of common law damages

Division 1 — 1993 scheme

19IA.Guides for assessing degree of disability50

19J.Assessment of degree of disability50

19JA.Method of referral and notification when Act s. 93EA(3) applies51

19JB.Method of referral and notification when Act s. 93EB(3) applies52

19K.Agreement as to degree of disability53

19L.Determination of degree of disability53

19M.Election to retain right to seek common law damages54

19N.Extension of time to make election under Act s. 93E(3)(b)55

19O.Application for compensation58

19P.Notification to workers about elections as to common law damages58

Division 2 — 2004 scheme

20.Recording agreement59

21.Recording assessment60

22.Electing to retain right to seek damages61

24.Expected time for approved medical specialist to give assessment documents62

25.Notice relating to common law claims62

Part 4  Registered agents

Division 1 — Preliminary

26.Terms used64

27.Prescribed organisations (Act s. 277(1)(e))65

27A.Prescribed classes of persons (Act s. 277(1)(f))65

Division 2 — Registration and renewal

28.Application for registration65

29.Registration67

30.Indemnity and other conditions of registration68

31.Duration of registration69

32.Application for renewal of registration70

33.Certificate of registration70

34.False or misleading information71

Division 3 — The register

35.Register71

36.Removal from register72

Division 4 — Disciplinary powers

37.Restriction on exercise of powers72

38.Cancellation of registration73

39.Taking disciplinary action73

40.Return of certificate of registration73

Division 5 — Review

41.Review by SAT74

Division 6 — Miscellaneous

42.Evidentiary matters74

Part 5 — Injury management

44.Vocational rehabilitation services76

44A.Counselling psychology79

44B.Exercise physiology79

44C.Acupuncture80

45.Insurer to advise of injury management obligations80

Part 6  Specialised retraining programs

47.Recording agreement82

48.Extending final day83

49.Request for WorkCover to direct payment84

Part 7  Infringement notices and modified penalties

50.Prescribed offences85

51.Prescribed modified penalties85

52.Prescribed form of infringement notice85

53.Prescribed form of withdrawal of notice85

Part 8 — Lodging documents

54.Terms used86

55.Completion of documents87

56.EDS exempt87

57.Lodging documents88

58.Lodging by email89

59.Day of lodgment89

60.Notification by Director90

Part 9 — Variation of certain amounts

61.Amount C (Act s. 5A(1A))91

62.Prescribed amount (Act s. 5A(1A))91

63.Board and lodging value (Act Sch. 1 cl. 15)91

64.Wheeled chair or similar appliance expenses (Act Sch. 1 cl. 17(4))92

65.Meals and lodging cost (Act Sch. 1 cl. 19(1))92

66.Rounding93

Part 10 — Prescribed diseases: presumption of work‑related injury

67.COVID‑19: prescribed disease and prescribed employment (Act s. 49F)94

Appendix I

Appendix II

Appendix III

Appendix IV — Registered agents code of conduct

1.Duties of registered agent227

2.Integrity and diligence227

3.Confidentiality228

4.Conflict of interest228

5.Proceedings229

6.Advertising230

7.Withdrawal230

8.Fees231

9.Records232

10.Trust moneys232

11.Costs232

Appendix V — Prescribed offences and modified penalties

Notes

Compilation table237

Other notes243

Defined terms

 

Workers’ Compensation and Injury Management Act 1981

Workers’ Compensation and Injury Management Regulations 1982

Part 1  Preliminary

[Heading inserted: Gazette 26 Feb 1991 p. 933.]

1.Citation

These regulations may be cited as the Workers’ Compensation and Injury Management Regulations 1982.

[Regulation 1 amended: 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.

2AAA.Terms used

In these regulations —

CPI means the all groups consumer price index for Perth published by the Australian Statistician;

December WPI, for a financial year, means the WPI for the last December quarter before the financial year;

March CPI, for a financial year, means the CPI for the last March quarter before the financial year;

WPI means the wage price index for ordinary time hourly rates of pay excluding bonuses (all sectors) (original) for Western Australia published by the Australian Statistician.

[Regulation 2AAA inserted: SL 2020/188 r. 4.]

2AA.Notes not part of regulations

Notes in these regulations are provided to assist understanding and do not form part of the regulations.

[Regulation 2AA inserted: Gazette 27 Jul 2012 p. 3665.]

Part 2  General

[Heading inserted: Gazette 26 Feb 1991 p. 933.]

2A.Indexation of redemption amount

(1)If the minimum award rates that would be relevant to calculating the redemption amount (as defined in Schedule 5 clause 1 of the Act) 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)The amount is varied by the percentage by which the December WPI varies from the previous December WPI.

[Regulation 2A inserted: Gazette 17 Nov 2000 p. 6309‑10; amended: Gazette 28 Oct 2005 p. 4861; 19 Mar 2010 p. 1038; 29 Jun 2018 p. 2443; SL 2020/188 r. 5.]

3.Certain registered bodies specified for definition of company (Act s. 5(1))

(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: Gazette 28 Sep 2001 p. 5357.]

3A.Instruments under Commonwealth laws prescribed for definition of industrial award in Act

For the purposes of paragraph (d) of the definition of industrial award in section 5(1) of the Act, the following instruments are prescribed —

(a)a fair work instrument as defined in the Fair Work Act 2009 (Commonwealth) section 12;

(b)an award‑based transitional instrument as defined in the Fair Work (Transitional Provisions and Consequential Amendments) Act 2009 (Commonwealth) Schedule 2 item 2 that continues in existence under Schedule 3 Part 2 of that Act.

[Regulation 3A inserted: Gazette 15 Apr 2016 p. 1185.]

4A.Certain mines, mining operations prescribed for 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: 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: 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: 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), (3)deleted]

[Regulation 6AA inserted: Gazette 28 Jun 1991 p. 3291; amended: 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; 29 Jun 2018 p. 2443.]

6AB.Relevant document (Act s. 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: Gazette 28 Oct 2005 p. 4863.]

6A.Form of first certificate of capacity

(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 must be completed accordingly.

[Regulation 6A inserted: Gazette 8 Mar 1991 p. 1071; amended: Gazette 13 Apr 1999 p. 1532; 28 Oct 2005 p. 4863; 18 Nov 2011 p. 4820; 25 Mar 2014 p. 821.]

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: 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: 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: 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: 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: Gazette 8 Mar 1991 p. 1071.]

6G.Giving notices under Act s. 57A and s. 57B and r. 25

(1)A notice under section 57A or 57B of the Act or regulation 25 may be given to a worker or an employer by emailing the notice to an email address nominated by the worker or employer (whichever is relevant).

(2)A worker or employer is taken to have nominated an email address as described in subregulation (1) if the email address is included in the worker’s claim for compensation.

[Regulation 6G inserted: SL 2020/188 r. 6.]

7.Discontinuance or reduction of weekly payments

(1)The certificate of capacity 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 certificate of capacity.

(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: Gazette 29 Oct 1993 p. 5930; 13 Apr 1999 p. 1532; 18 Nov 2011 p. 4820; 25 Mar 2014 p. 821.]

7A.Form of progress certificate of capacity

Form 4A in Appendix 1 is prescribed as a certificate for the purposes of section 61(1) of the Act.

[Regulation 7A inserted: Gazette 25 Mar 2014 p. 821.]

8.Frequency and time of medical examinations (Act s. 66)

(1)A worker who receives a first certificate of capacity (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 certificate of capacity (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 certificate of capacity 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: Gazette 13 Apr 1999 p. 1532‑3; amended: Gazette 28 Oct 2005 p. 4863‑4; 25 Mar 2014 p. 821.]

[8A.Deleted: 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: 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

Y =the whole number equal to or next below

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: Gazette 25 Jul 1986 p. 2484; amended: Gazette 2 Sep 1988 p. 3464.]

10.Worker not residing in State

(1)For the purposes of section 69, a worker must send to the employer or the employer’s insurer a declaration by the worker and a medical practitioner in the form of Appendix I Form 6 —

(a)within 3 months after the date on which the worker is no longer residing in the State; and

(b)for each subsequent period during which the worker continues to receive weekly payments while not residing in the State, within 3 months after the date of the previous declaration by the worker and a medical practitioner.

(2)A declaration under subregulation (1) is taken to have been sent to an employer or an employer’s insurer at the time it was —

(a)delivered personally to the last known business address of the employer or the employer’s insurer; or

(b)posted to the last known business address of the employer or the employer’s insurer; or

(c)sent by electronic means to the last known email address or fax number of the employer or the employer’s insurer.

(3)An employer or an employer’s insurer who disputes the identity or entitlement, or both, of a worker may apply —

(a)under section 182E of the Act for resolution of the dispute by conciliation; and

(b)under section 182ZT of the Act for determination of the dispute by arbitration, if the dispute is not resolved by conciliation.

[Regulation 10 inserted: Gazette 4 Oct 2016 p. 4242-3.]

[10A.Deleted: Gazette 18 Nov 2011 p. 4821.]

[10B.Deleted: Gazette 28 Oct 2005 p. 4864.]

11.Payments after death outside 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: Gazette 18 Feb 1994 p. 661.]

11A.Amount to discharge liability for child’s allowance (Act s. 72J(5))

(1)In this regulation —

relevant year, in relation to the payment of an amount to WorkCover WA under section 72J(5) of the Act, means the financial year in which the amount is to be paid.

(2)For the purposes of section 72J(5) of the Act, the amount to be paid to WorkCover WA is to be calculated as follows —

where —

Cis the child’s allowance (as defined in Schedule 1A clause 5 of the Act);

Wis the percentage by which WPI varied between the second-last December quarter before the relevant year commenced and the last December quarter before the relevant year commenced;

Nis the number of weeks until the child attains the age of 21 years.

[Regulation 11A inserted: Gazette 29 Jun 2018 p. 2443‑4; amended: SL 2020/188 r. 7.]

12.Agreements

(1AA)In this regulation —

lodge means to lodge in accordance with regulation 57.

(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 lodging it as soon as practicable after the agreement has been entered into.

(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.

(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), lodge a notice in the form of Form 15E in Appendix I.

(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 lodge 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: Gazette 18 Feb 1994 p. 661; amended: Gazette 15 Oct 1999 p. 4906‑7; 28 Oct 2005 p. 4864‑5; 18 Nov 2011 p. 4821; SL 2020/149 r. 4.]

12AA.Notice of intention to dismiss worker (Act s. 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: Gazette 28 Oct 2005 p. 4865.]

[12AB.Deleted: 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: Gazette 22 May 1987 p. 2193; amended: 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 (Act s. 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: Gazette 26 Oct 2004 p. 4898‑9; amended: Gazette 21 Jan 2005 p. 276.]

13A.Prescribed rate of interest (Act s. 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: Gazette 28 Oct 2005 p. 4866.]

14.Insurance requirement (Act s. 160(1))

(1)Section 160(1) of the Act does not require an employer to obtain or keep current a policy of insurance for liability to pay compensation under the Act or damages arising out of —

(a)a claim directly or indirectly occasioned by any event happening through or in consequence of —

(i)war; or

(ii)invasion; or

(iii)acts of foreign enemies; or

(iv)hostilities whether war be declared or not; or

(v)civil war; or

(vi)rebellion; or

(vii)revolution; or

(viii)insurrection; or

(ix)military or usurped power;

or

(b)a claim in respect of —

(i)pneumoconiosis; or

(ii)mesothelioma; or

(iii)lung cancer; or

(iv)diffuse pleural fibrosis,

arising from employment in any mine or mining operation; or

(c)a claim in respect of any other industrial disease for the time being specified by the Minister under section 151(a)(iii) of the Act.

(2)Section 160(1) of the Act does not require an employer to obtain or keep current a policy of insurance for liability to pay damages arising out of —

(a)a claim brought in respect of an injury occurring outside Australia; or

(b)a claim brought outside Australia.

(3)Section 160(1) of the Act does not require an employer to obtain or keep current a policy of insurance for liability to pay —

(a)exemplary or punitive damages; or

(b)an aggregate amount of damages exceeding $50 000 000 arising out of all claims in respect of a single event.

Note for this regulation:

The Workers’ Compensation and Injury Management (Acts of Terrorism) Act 2001 section 6 provides that, in stated circumstances, section 160 of the Act does not require an employer to insure against certain liabilities attributable to acts of terrorism.

[Regulation 14 inserted: Gazette 27 Jul 2012 p. 3665‑6.]

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: Gazette 8 Mar 2002 p. 949; amended: Gazette 16 Sep 2003 p. 4104; 21 Jan 2005 p. 276.]

[16.Deleted: Gazette 28 Oct 2005 p. 4866.]

16A.Clause 1C notifications and elections (Act Sch. 1 cl. 1C, Sch. 8 cl. 10)

(1A)This regulation applies only if the injury of a worker occurred and the worker died before 1 July 2018.

(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; and

(b)specify —

(i)the name and address of the dependant; and

(ii)the relationship (child or step‑child) of the dependant to the deceased worker; and

(iii)the name of the deceased worker, and the address of the deceased worker at the time of death; and

(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; and

(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; and

(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;

and

(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; and

(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: Gazette 28 Oct 2005 p. 4867‑8; amended: Gazette 29 Jun 2018 p. 2444.]

17.Prescribed allowance (Act Sch. 1 cl. 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: Gazette 21 Jan 2005 p. 275; amended: Gazette 28 Oct 2005 p. 4868.]

[17AAA. Deleted: SL 2020/188 r. 8.]

17AA.Prescribed rate for vehicle running expenses (Act Sch. 1 cl. 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)deleted]

[Regulation 17AA inserted: Gazette 29 Oct 2004 p. 4939‑40; amended: Gazette 28 Oct 2005 p. 4868; SL 2020/188 r. 9.]

17AB.Exceptional circumstances (Act Sch. 1 cl. 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;

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: Gazette 28 Oct 2005 p. 4868‑9; amended: Gazette 18 Nov 2011 p. 4821; SL 2020/149 r. 5.]

17AC.Management plan (Act Sch. 1 cl. 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: 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: Gazette 28 Oct 2005 p. 4870‑1.]

17AE.Amount prescribed for funeral expenses (Act Sch. 1 cl. 17(2), Sch. 8 cl. 10(1))

(1A)This regulation applies only if the injury of a worker occurred and the worker died before 1 July 2018.

(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, 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)deleted]

[Regulation 17AE inserted: Gazette 4 Aug 2006 p. 2855‑6; amended: Gazette 29 Jun 2018 p. 2444; SL 2020/188 r. 10.]

17AF.Amount prescribed for child’s allowance (Act Sch. 1A cl. 5(b))

[(1)deleted]

(2)For the purposes of Schedule 1A clause 5(b) of the Act, the child’s allowance is —

(a)for the financial year commencing on 1 July 2018, the amount of $135 per week; and

(b)for a financial year commencing on or after 1 July 2019 (the relevant year), the amount per week determined by —

(i)varying the amount for the preceding financial year by the percentage by which WPI varied between the second-last December quarter before the relevant year commenced and the last December quarter before the relevant year commenced; and

(ii)rounding the amount to the nearest whole number of dollars (with an amount that is 50 cents more than a whole number being rounded up to the next highest whole number).

(3)Despite subregulation (2)(b), if the amount determined under that subregulation would result in a decrease in the amount prescribed for the child’s allowance, the amount prescribed is the same amount as the amount for the preceding financial year.

[Regulation 17AF inserted: Gazette 29 Jun 2018 p. 2444‑5; amended: SL 2020/188 r. 11.]

17AG.Amount prescribed for funeral expenses (Act Sch. 1A cl. 9(2)(b))

[(1)deleted]

(2)For the purposes of Schedule 1A clause 9(2)(b) of the Act, the amount prescribed for funeral expenses is —

(a)for the financial year commencing on 1 July 2018, $9 903; and

(b)for a financial year commencing on or after 1 July 2019 (the relevant year), the amount determined by —

(i)varying the amount for the preceding financial year by the percentage by which CPI varied between the second-last March quarter before the relevant year commenced and the last March quarter before the relevant year commenced; and

(ii)rounding the amount to the nearest whole number of dollars (with an amount that is 50 cents more than a whole number being rounded up to the next highest whole number).

(3)Despite subregulation (2)(b), if the amount determined under that subregulation would result in a decrease in the amount prescribed for funeral expenses, the amount prescribed is the same amount as the amount for the preceding financial year.

[Regulation 17AG inserted: Gazette 29 Jun 2018 p. 2445‑6; amended: SL 2020/188 r. 12.]

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, 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)deleted]

[Regulation 17A inserted: Gazette 2 Nov 2007 p. 5933‑4; amended: SL 2020/188 r. 13.]

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: Gazette 28 Oct 2005 p. 4871; amended: 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: Gazette 17 Nov 2000 p. 6312.]

Part 2A  Assessment of costs

[Heading inserted: 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: 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: Gazette 28 Oct 2005 p. 4872; amended: 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: Gazette 28 Oct 2005 p. 4872; amended: 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: Gazette 28 Oct 2005 p. 4872‑3; amended: 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: 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: 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: 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: 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: 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: 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: 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 2 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: Gazette 18 Nov 2011 p. 4822‑3.]

Part 2B  Medical assessment

[Heading inserted: 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; and

(b)details sufficient to enable the worker to be contacted; and

(c)the worker’s date of birth; and

(d)the date on which the worker’s injury occurred; and

(e)a description of the worker’s injury; and

(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; and

(g)the employer’s name and address and any other details necessary to identify the employer; and

(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); or

(b)Part IV Division 2 Subdivision 3 of the Act (which provides for restrictions on awarding, and the amount of, damages); or

(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: 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; and

(b)the approved medical specialist’s name; and

(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: 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; and

(ii)the approved medical specialist’s name; and

(iii)details sufficient to enable the approved medical specialist to be contacted; and

(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: 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; and

(b)details of any relevant document or information to which the requirement applies; and

(c)the approved medical specialist’s name; and

(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; and

(b)details of any relevant document or information to which the requirement applies; and

(c)the name of the person who has the relevant document or information; and

(d)the approved medical specialist’s name; and

(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: 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: 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: 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; and

(b)the approved medical specialist’s name; and

(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; 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; and

(b)the approved medical specialist’s name; and

(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; and

(b)the approved medical specialist’s name; and

(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; 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: 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; and

(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: 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; and

(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; and

(b)details of any relevant document or information to which the requirement applies; and

(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: 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: 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: 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; and

(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: Gazette 28 Oct 2005 p. 4884.]

[19.Deleted: Gazette 8 Mar 2002 p. 949.]

Part 3  Noise induced hearing loss

[Heading inserted: 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: Gazette 26 Feb 1991 p. 934; amended: 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; and

(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: Gazette 26 Feb 1991 p. 934; amended: 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; or

(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; and

(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: Gazette 26 Feb 1991 p. 935‑7; amended: 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: Gazette 26 Feb 1991 p. 937; amended: 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: Gazette 26 Feb 1991 p. 937; amended: 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: Gazette 26 Feb 1991 p. 937‑8; amended: Gazette 17 Nov 2000 p. 6312; 21 Jan 2005 p. 276; 28 Oct 2005 p. 4885.]

[19G.Deleted: 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; or

(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; and

(ii)whether the worker’s hearing loss is due, or partly due, to ear disease; and

(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: Gazette 26 Feb 1991 p. 938‑9; amended: 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: Gazette 26 Feb 1991 p. 939.]

Part 3AConstraints on awards of common law damages

[Heading inserted: Gazette 15 Oct 1999 p. 4890.]

Division 1 — 1993 scheme

[Heading inserted: 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: Gazette 17 Nov 2000 p. 6312‑13; amended: 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: Gazette 15 Oct 1999 p. 4890‑1; amended: 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 Act s. 93EA(3) 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: Gazette 26 Oct 2004 p. 4899‑900; amended: Gazette 28 Oct 2005 p. 4911.]

19JB.Method of referral and notification when Act s. 93EB(3) 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: Gazette 26 Oct 2004 p. 4900‑1; amended: 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: Gazette 15 Oct 1999 p. 4891; amended: 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: Gazette 15 Oct 1999 p. 4891; amended: 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;

and

(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.

[Regulation 19M inserted: Gazette 14 Dec 1999 p. 6147‑8; amended: Gazette 17 Nov 2000 p. 6313‑14.]

19N.Extension of time to make election under Act s. 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; or

(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; or

(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; and

(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; and

(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; and

(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; and

(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; and

(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: Gazette 14 Dec 1999 p. 6149‑50; amended: 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: Gazette 15 Oct 1999 p. 4892; amended: 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: Gazette 14 Dec 1999 p. 6150‑1; amended: Gazette 17 Nov 2000 p. 6316‑17; 21 Jan 2005 p. 276; 28 Oct 2005 p. 4886.]

Division 2 — 2004 scheme

[Heading inserted: 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; and

(b)details sufficient to enable the worker to be contacted; and

(c)the worker’s date of birth; and

(d)the date on which the injury occurred and a description of the injury; and

(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); and

(f)the employer’s name and any other details necessary to identify the employer; and

(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: 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%; and

(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: 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 in accordance with regulation 57.

(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 as soon as practicable after the election form is lodged; 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: Gazette 28 Oct 2005 p. 4889; amended: SL 2020/149 r. 6.]

[23.Deleted: SL 2020/188 r. 14.]

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: Gazette 28 Oct 2005 p. 4892.]

25.Notice relating to common law claims

(1)In this regulation —

approved form means a form approved by the chief executive officer.

(2)This regulation applies in relation to a claim by a worker for compensation by way of weekly payments.

(3)If an insurer notifies the worker under section 57A of the Act that liability is accepted in relation to the claim, the insurer must at the same time notify the worker, in the approved form, of the effect of the provisions of Part IV Division 2 Subdivision 3.

Penalty for this subregulation: a fine of $1 000.

(4)If a self‑insurer accepts liability in relation to the claim, the self‑insurer must on or before making the 1st weekly payment notify the worker, in the approved form, of the effect of the provisions of Part IV Division 2 Subdivision 3.

Penalty for this subregulation: a fine of $1 000.

[Regulation 25 inserted: SL 2020/188 r. 15.]

Part 4  Registered agents

[Heading inserted: Gazette 28 Oct 2005 p. 4893.]

Division 1 — Preliminary

[Heading inserted: 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: Gazette 28 Oct 2005 p. 4893; amended: Gazette 9 Dec 2005 p. 5892.]

27.Prescribed organisations (Act s. 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: Gazette 9 Dec 2005 p. 5892.]

27A.Prescribed classes of persons (Act s. 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: Gazette 9 Dec 2005 p. 5892‑3; amended: Gazette 18 Nov 2011 p. 4823.]

Division 2 — Registration and renewal

[Heading inserted: 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: Gazette 28 Oct 2005 p. 4894‑5; amended: 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; and

(ii)verified by statutory declaration of the agent; and

(iii)accepted by WorkCover WA.

[Regulation 29 inserted: Gazette 28 Oct 2005 p. 4895; amended: 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; and

(ii)verified by statutory declaration of the agent; and

(iii)accepted by WorkCover WA.

[Regulation 30 inserted: Gazette 28 Oct 2005 p. 4895‑6; amended: 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: 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: Gazette 28 Oct 2005 p. 4896‑7; amended: 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: 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: Gazette 28 Oct 2005 p. 4897.]

Division 3 — The register

[Heading inserted: 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; and

(b)the name and address of the employer, if any, of the registered agent; and

(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: Gazette 28 Oct 2005 p. 4898; amended: 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: Gazette 28 Oct 2005 p. 4898‑9.]

Division 4 — Disciplinary powers

[Heading inserted: 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: Gazette 28 Oct 2005 p. 4899; amended: 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: 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; or

(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; or

(b)attach a condition to the registration; or

(c)suspend the registration for a period not exceeding 12 months; or

(d)cancel the registration.

[Regulation 39 inserted: 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: Gazette 28 Oct 2005 p. 4900.]

Division 5 — Review

[Heading inserted: Gazette 28 Oct 2005 p. 4900.]

41.Review by SAT

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: Gazette 28 Oct 2005 p. 4900.]

Division 6 — Miscellaneous

[Heading inserted: 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: Gazette 28 Oct 2005 p. 4901.]

[43.Deleted: Gazette 18 Nov 2011 p. 4823.]

Part 5  Injury management

[Heading inserted: 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 item

column 2
service

column 3
description

1

support counselling

activities to assist 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 counselling

activities focussed on problems the worker has in selecting and preparing for vocational change

3

purchase of aids and appliances

advising and assisting 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 criteria assistance

assisting a worker to explore eligibility to participate in a specialised retraining program and to prepare information to show that the retraining criteria are satisfied

6

specialised retraining program assistance

services to assist a worker undertake a specialised retraining program

7

training and education

assisting to develop the worker’s skills and knowledge, which may include providing training courses or other aspects of injury management

8

workplace activities

activities involving analysis of work behaviour and analysis and design of job duties

9

placement activities

activities focussed on 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 capacity

activities associated 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 appliances

activities associated 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: 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: 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 Exercise and Sports Science Australia.

(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: Gazette 17 Dec 2008 p. 5333‑4; amended: Gazette 14 Dec 2012 p. 6209.]

44C.Acupuncture

(1)In this regulation —

acupuncturist means —

(a)a person whose name is entered on the Register of Chinese Medicine Practitioners kept under the Health Practitioner Regulation National Law (Western Australia) in the Division of acupuncture; or

(b)a health practitioner registered under the Health Practitioner Regulation National Law (Western Australia) to practice a health profession and whose registration is endorsed for acupuncture.

(2)Where acupuncture is approved under section 5(1) of the Act as an approved treatment for workers suffering an injury that is compensable under the Act, that treatment can only be provided by an acupuncturist.

[Regulation 44C inserted: Gazette 20 Mar 2015 p. 910‑11.]

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; and

(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: Gazette 28 Oct 2005 p. 4905‑6.]

[46.Deleted: Gazette 18 Nov 2011 p. 4823.]

Part 6  Specialised retraining programs

[Heading inserted: 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; and

(b)details sufficient to enable the worker to be contacted; and

(c)the worker’s date of birth; and

(d)the date on which the injury occurred and a description of the injury; and

(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); and

(f)the employer’s name and any other details necessary to identify the employer; and

(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: 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;

and

(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: 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; and

(b)the worker’s name and any other details necessary to identify the worker; and

(c)details sufficient to enable the worker to be contacted; and

(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: Gazette 28 Oct 2005 p. 4909‑10.]

Part 7  Infringement notices and modified penalties

[Heading inserted: 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: 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: 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: 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: Gazette 28 Oct 2005 p. 4911.]

Part 8 — Lodging documents

[Heading inserted: SL 2020/149 r. 8.]

54.Terms used

In this Part —

agreement means either —

(a)an agreement referred to in section 76(1) of the Act; or

(b)an agreement referred to in section 92(f) of the Act;

application means an application or election made for the purposes of Part IV Division 2 of the Act;

EDS means the electronic document system operated by or on behalf of the Director that, amongst other things, enables Part 8 documents to be lodged with the Director;

EDS exempt, in relation to an agreement or application, has the meaning given in regulation 56;

Part 8 document means any of the following —

(a)an election, determination, agreement, notice, application or other thing in the form of a Form 1, 1A, 2, 2C, 2CA, 14, 15C, 15D, 15E, 34 or 35 in Appendix I;

(b)written consent referred to in regulation 12(6);

(c)a written request referred to in regulation 20 or 21;

(d)a memorandum referred to in section 92(f) of the Act;

(e)any document accompanying a document referred to in paragraphs (a) to (d);

(f)any document the Director considers relevant to an agreement or application.

[Regulation 54 inserted: SL 2020/149 r. 8.]

55.Completion of documents

Every Part 8 document —

(a)where relevant, must be clearly written, typed or reproduced; and

(b)must be properly completed.

[Regulation 55 inserted: SL 2020/149 r. 8.]

56.EDS exempt

(1)A person is EDS exempt in relation to an agreement or application at a particular time if, at that time —

(a)the person —

(i)is a party to the agreement or the person who lodged the application; and

(ii)is self‑represented in relation to the agreement or application; and

(iii)is neither an insurer nor a self‑insurer;

or

(b)the person is exempt in relation to the agreement or application under subregulation (3).

(2)A person is self‑represented in relation to an agreement or application if —

(a)in the case of a worker — a legal practitioner is not engaged by or on behalf of the worker in relation to the agreement or application; or

(b)in the case of an employer — the employer is uninsured.

(3)The Director may exempt a person from a requirement to use the EDS in relation to —

(a)an agreement or application, if satisfied that it would be unreasonable for the person to be required to use the EDS in relation to the agreement or application; or

(b)all agreements and applications, if satisfied that it would be unreasonable for the person to be required to use the EDS in relation to the agreements and applications.

[Regulation 56 inserted: SL 2020/149 r. 8.]

57.Lodging documents

(1)A Part 8 document in relation to an agreement or application must be lodged using the EDS unless —

(a)the person lodging the document is EDS exempt in relation to the agreement or application; or

(b)the EDS is unavailable at the time of lodging.

(2)A person who is EDS exempt in relation to an agreement or application may lodge a Part 8 document in relation to the agreement or application with the Director in the following manner —

(a)by presenting it at the office of the Director when the office is open for business; or

(b)by sending it to the office of the Director by pre‑paid post; or

(c)by sending it to the Director by email in accordance with regulation 58(2) and (3); or

(d)by using the EDS.

(3)While the EDS is unavailable for use a Part 8 document may be lodged in the manner referred to in subregulation (2)(a), (b) or (c).

(4)The Director may at any time require a person who has lodged a Part 8 document by email or by using the EDS to lodge the document in person or by post.

(5)A person who lodges an agreement under this regulation must confirm that the agreement has been executed in accordance with the laws of the State.

[Regulation 57 inserted: SL 2020/149 r. 8.]

58.Lodging by email

(1)For the purposes of regulation 57(2)(c), the Director may —

(a)approve and publish an email address for the lodgment of documents under this regulation; and

(b)determine and publish requirements as to the permissible format and the maximum size of documents that may be lodged under this regulation.

(2)An email by which documents are lodged under this regulation must —

(a)state the sender’s name; and

(b)state a telephone number by which the sender can be contacted; and

(c)list and describe the documents being lodged by the email.

(3)Documents lodged under this regulation must comply with any published requirements as to format and size.

[Regulation 58 inserted: SL 2020/149 r. 8.]

59.Day of lodgment

(1)In this regulation —

working day means a day other than a Saturday, a Sunday or a public holiday throughout the State.

(2)A document is taken to have been lodged —

(a)if the whole document is received before 5 pm on a particular working day, on that day; or

(b)otherwise, on the next working day.

[Regulation 59 inserted: SL 2020/149 r. 8.]

60.Notification by Director

(1)In this regulation —

electronic notification, in relation to a person, includes notification by an email sent to an email address provided by the person;

notify includes to despatch or send a notice to.

(2)A requirement for the Director to notify a person, or give them a copy of a document, in relation to an agreement or application is satisfied, on a day, if —

(a)before 5 pm on that day —

(i)the notice or document becomes accessible to the person by using the EDS; and

(ii)electronic notification that the notice or document is accessible is sent to the person;

or

(b)the notice or document is sent to the person by pre‑paid post 2 business days before that day; or

(c)the notice or document is sent to an email address provided by the person before 5 pm on that day.

(3)Subregulation (2)(a) does not apply if the person —

(a)is EDS exempt in relation to the agreement or application; and

(b)does not have access to the EDS in relation to the agreement or application.

[Regulation 60 inserted: SL 2020/149 r. 8.]

Part 9 — Variation of certain amounts

[Heading inserted: SL 2020/188 r. 16.]

61.Amount C (Act s. 5A(1A))

For the purposes of paragraph (c) of the definition of Amount C in section 5A(1A) of the Act, the amount for a financial year is worked out by multiplying by 2 the average of the amounts that the Australian Statistician published as the all employees average weekly total earnings in Western Australia for pay periods ending in the months of May and November preceding the financial year.

Note for this regulation:

Under section 5A(5) of the Act a variation that would reduce the amount has no effect.

[Regulation 61 inserted: SL 2020/188 r. 16.]

62.Prescribed amount (Act s. 5A(1A))

For the purposes of paragraph (c) of the definition of prescribed amount in section 5A(1A) of the Act, the amount for a financial year is worked out by varying the prescribed amount for the previous financial year by the percentage by which the December WPI varies from the previous December WPI.

Note for this regulation:

Under section 5A(5) of the Act a variation that would reduce the amount has no effect.

[Regulation 62 inserted: SL 2020/188 r. 16.]

63.Board and lodging value (Act Sch. 1 cl. 15)

(1)This regulation has effect for the purposes of assessing the value of board or board and lodging under Schedule 1 clause 15 of the Act for a financial year commencing on or after 1 July 2021.

(2)For the purposes of section 5A(1)(c) of the Act, the amount, which the sum assessed for the board or board and lodging is not to exceed, is the amount per day worked out by varying the amount per day for the previous financial year by the percentage by which the March CPI varies from the previous March CPI.

Notes for this regulation:

1.The amount for the financial year commencing on 1 July 2020 is $157 per day.

2.Under section 5A(5) of the Act a variation that would reduce the amount has no effect.

[Regulation 63 inserted: SL 2020/188 r. 16.]

64.Wheeled chair or similar appliance expenses (Act Sch. 1 cl. 17(4))

(1)This regulation has effect for the purposes of assessing the reasonable expenses incurred or likely to be incurred in respect of the purchase or supply of a wheeled chair or similar appliance under Schedule 1 clause 17(4) of the Act for a financial year commencing on or after 1 July 2021.

(2)For the purposes of section 5A(1)(c) of the Act, the amount, which the sum payable for those expenses is not to exceed, is the amount worked out by varying the amount for the previous financial year by the percentage by which the March CPI varies from the previous March CPI.

Notes for this regulation:

1.The amount for the financial year commencing on 1 July 2020 is $12 180.

2.Under section 5A(5) of the Act a variation that would reduce the amount has no effect.

[Regulation 64 inserted: SL 2020/188 r. 16.]

65.Meals and lodging cost (Act Sch. 1 cl. 19(1))

(1)This regulation has effect for the purposes of assessing the reasonable costs incurred for meals and lodging under Schedule 1 clause 19(1) of the Act for a financial year commencing on or after 1 July 2021.

(2)For the purposes of section 5A(1)(c) of the Act, the amount, which the amount payable for those costs is not to exceed, is the amount per day worked out by varying the amount per day for the previous financial year by the percentage by which the March CPI varies from the previous March CPI.

Notes for this regulation:

1.The amount for the financial year commencing on 1 July 2020 is $121 per day.

2.Under section 5A(5) of the Act a variation that would reduce the amount has no effect.

[Regulation 65 inserted: SL 2020/188 r. 16.]

66.Rounding

An amount worked out under this Part must be rounded to the nearest whole dollar with an amount that is 50 cents more than a whole dollar being rounded up to the next whole dollar.

[Regulation 66 inserted: SL 2020/188 r. 16.]

Part 10 — Prescribed diseases: presumption of work‑related injury

[Heading inserted: SL 2020/188 r. 16.]

67.COVID‑19: prescribed disease and prescribed employment (Act s. 49F)

(1)In this regulation —

health professional means a person registered under the Health Practitioner Regulation National Law (Western Australia) in a health profession;

NATA means the National Association of Testing Authorities.

(2)For the purposes of section 49F(1)(a) of the Act, COVID‑19 is specified as a prescribed disease.

(3)For the purposes of section 49F(1)(b) of the Act, the following kinds of employment are specified as prescribed employment for COVID‑19 —

(a)employment as a health professional;

(b)employment, of any kind, in a hospital, medical practice, clinic or facility where persons attend for health related screening, testing or treatment;

(c)employment as an ambulance officer.

(4)For the purposes of section 49F(3) of the Act, a worker who suffers an injury by contracting COVID‑19 is taken to have suffered the injury —

(a)if paragraph (b) does not apply — on the day on which the worker is diagnosed as having COVID‑19 by a medical practitioner on the basis of a test result described in subregulation (6); or

(b)if the worker dies as a result of contracting COVID‑19 before they are diagnosed as described in paragraph (a) — on the day on which the worker dies.

(5)Section 49F(3) of the Act does not apply to a worker who suffers an injury by contracting COVID‑19 if —

(a)the day on which the worker is taken, under subregulation (4), to have suffered the injury is before 16 February 2020; or

(b)the worker is not in prescribed employment for COVID‑19 on the day on which the worker is taken, under subregulation (4), to have suffered the injury.

(6)For the purposes of subregulation (4)(a), the test results are as follows —

(a)detection of SARS‑CoV‑2 using a SARS‑CoV‑2 specific nucleic acid test by a NATA accredited laboratory;

(b)isolation of SARS‑CoV‑2 in a cell culture, with confirmation using a SARS‑CoV‑2 specific nucleic acid test, by a NATA accredited laboratory;

(c)confirmation of SARS‑CoV‑2 specific antibodies by a NATA accredited laboratory.

[Regulation 67 inserted: SL 2020/188 r. 16.]

 

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: 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)

SurnameMr/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: 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: 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: 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:

r less than one day

r 1-4 work days (inclusive)

r 5-9 work days (inclusive)

r 10-20 work days (inclusive)

r more than 20 work days

r 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 certificate of capacity from the injured worker:

Date employer sent the claim form and certificate/s of capacity to
insurer:

Worker please complete

Surname:

Other names:

Date of birth:

r Male r 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:

r direct employee

r working director

r contractor

r employee of a contractor

r subcontractor

r visa worker

r other

At the time of the injury I was engaged as:

r full-time

r part-time

r permanent

r temporary

r 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:

r working — at your normal workplace

r working — away from normal workplace

r working — road traffic accident

r on work break — at normal workplace

r on work break — away from normal workplace

r other duty status

r 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: Gazette 10 Sep 2010 p. 4352-7; amended: Gazette 18 Nov 2011 p. 4824; 25 Mar 2014 p. 822.]

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)

SurnameMr/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/TownPost 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 o Yes o No

Baseline TestDate......./......../........PLH o o. o o /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 TestDate......./......../........PLH o o. o o

Subsequent TestDate......./......../........PLH o o. o o

Subsequent TestDate......./......../........PLH o o. o o

Subsequent TestDate......./......../........PLH o o. o o

Subsequent TestDate......./......../........PLH o o. o o

Subsequent TestDate......./......../........PLH o o. o o

Subsequent TestDate......./......../........PLH o o. o o

Subsequent Full

Audio TestDate......./......../........PLH o o. o o

Otorhinolarynigological

assessmentDate......./......../........NIHLPLH o o. o o

Number of years with this employer since the baseline test/March 1, 1991 o o

Termination Date......./......../........

Subsequent test

at terminationDate......./......../........PLH o o. o o

NIHL Claims Officer

check:Date......./......../........Signature

NIHL Manager

check:Date......./......../........Signature

[Form 2C inserted: Gazette 25 Aug 1995 p. 3885‑7; amended: 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)

SurnameMr/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/TownPost 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 o Yes o No

Baseline Test Date....../......./....... PLH o o. o o / 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 TestDate....../......./.......PLH o o. o o

Subsequent TestDate....../......./.......PLH o o. o o

Subsequent TestDate....../......./.......PLH o o. o o

Subsequent TestDate....../......./.......PLH o o. o o

Subsequent TestDate....../......./.......PLH o o. o o

Subsequent TestDate....../......./.......PLH o o. o o

Subsequent TestDate....../......./.......PLH o o. o o

Subsequent Full Audio TestDate....../......./.......PLH o o. o o

Otorhinolaryngological
assessment
Date....../......./.......NIHLPLH o o. o o

Number of years with this employer since the baseline test/1 March 1991 o o

Termination Date......./......../........

Subsequent test at termination Date......./......../........PLH o o. o o

NIHL Claims Officer checkDate......./......../........Signature...................................

NIHL Manager checkDate......./......../........Signature..................................

[Form 2CA inserted: Gazette 28 Oct 2005 p. 4916‑19.]

[Form 2D deleted: Gazette 29 Jun 2018 p. 2446.]

Form 3

[r. 6A and 7(1)]

Workers’ Compensation and Injury Management Act 1981

(Sections 57A(1)(b), 57B(1)(b) and 61(1))

FIRST CERTIFICATE OF CAPACITY

1. WORKER’S DETAILS

First name

 

Last name

 

 

 

Date of birth

/ /

Email

 

 

 

Phone

 

Mobile

 

 

 

Address

 

 

 

2. EMPLOYMENT DETAILS

Worker’s job title

 

Employer’s name

 

 

 

Employer’s address

 

 

 

3. CONSENT AUTHORITY

I consent to any medical practitioner who treats me (whether named on this certificate or not) to discuss my medical condition with my employer, insurer and other medical or allied health professionals for the purpose of my claim for workers’ compensation and return to work options.

 

Worker’s signature

 

Print name

 

 

 

 

 

 

 

Date

/ /

 

 

4. WORKER’S DESCRIPTION OF INJURY

Date of injury

/ /

 

 

What happened?

 

 

 

Worker’s symptoms

 

 

 

5. MEDICAL ASSESSMENT

Date of this assessment

/ /

 

 

Clinical findings

 

 

 

 

 

 

Diagnosis

 

 

 

The injury is consistent with worker’s description

of how injury occurred

 

yes

 

no

 

uncertain

 

The injury is:

 

a new condition

 

a recurrence of a pre‑existing condition

 

6. WORK CAPACITY

Worker’s usual duties

 

 

 

Having considered the health benefits of work, I find this worker to have:

 

 

full capacity for work from

/ /

 

 

but requires further treatment

 

 

 

some capacity for work from

/ /

to

/ /

performing

 

 

 

pre‑injury duties

 

modified or alternative duties

 

workplace modifications

 

 

 

pre‑injury hours

 

modified hours of

 

hrs/day

 

days/wk

 

 

 

no capacity for any work from

/ /

to

/ /

(outline clinical reasons below)

 

Worker has capacity to:

(Please outline the worker’s physical and/or psychosocial capacity — refer to explanatory notes for examples. Where there is no capacity for work, please provide clinical reasoning.)

 

 

 

lift up to

 

kg

 

 

 

 

 

sit up to

 

mins

 

 

 

 

 

stand up to

 

mins

 

 

 

 

 

walk up to

 

m

 

 

 

 

 

work below shoulder height

 

 

 

7. INJURY MANAGEMENT PLAN

 

Activities/interventions

Purpose/goal
(likely change in symptoms, function, activity and work participation)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I would like:

 

more information about available duties

 

 

 

 

a RTW program to be established

 

 

 

 

 

to be involved in developing the RTW program

 

 

Examples of injury management activities/interventions include:

further assessment — diagnostic imaging, medical specialist consults, worksite assessment;

intervention — physiotherapy, clinical psychology, exercise physiology, prescribed medications, workplace mediation;

return to work planning — identify suitable duties, establish return to work program.

 

8. NEXT REVIEW DATE

 

 

 

Worker does not need to be reviewed again (FIRST and FINAL certificate of capacity)

 

 

 

I will review worker again on

/ /

(If greater than 14 days, please provide

 

 

 

 

clinical reasoning)

Comments

 

 

 

9. MEDICAL PRACTITIONER’S DETAILS

Name

 

AHPRA no. MED

 

 

 

 

 

 

 

 

 

 

 

Address

 

Email

 

 

 

 

 

Signature

 

 

 

 

Phone

 

 

 

 

Fax

 

Date

/ /

 

(Practice stamp — optional)

[Form 3 inserted: Gazette 25 Mar 2014 p. 822-4.]

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: Gazette 14 Dec 1999 p. 6151; amended: 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: Gazette 8 Mar 1991 p. 1074; amended: 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: Gazette 8 Mar 1991 p. 1075; amended: 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: Gazette 8 Mar 1991 p. 1075; amended: 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: Gazette 8 Mar 1991 p. 1075‑6; amended: 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 CERTIFICATE OF CAPACITY

1. WORKER’S DETAILS

First name

 

Last name

 

 

Date of birth

/ /

Claim no.

 

 

 

Phone

 

Email

 

 

 

Address

 

 

 

2. EMPLOYER’S DETAILS

Employer’s name

 

Employer’s phone

 

 

 

Employer’s address

 

 

 

3. MEDICAL ASSESSMENT

Date of this assessment

/ /

Date of injury

/ /

 

 

 

 

 

The worker’s condition is unlikely to change substantially in the next 12 months.

 

4. WORK CAPACITY

Having considered the health benefits of work, I find this worker to have:

 

 

full capacity for work from

/ /

 

 

but requires further treatment (specifics below)

 

 

 

 

capacity for work performing

 

hours per day and

 

days per week from

/ /

 

 

 

as outlined below:

(Please outline the worker’s physical and/or psychosocial capacity for work, functional limits, ongoing need for workplace modifications, and/or further treatment needs)

 

 

 

 

lift up to

 

kg

 

 

 

 

 

sit up to

 

mins

 

 

 

 

 

stand up to

 

mins

 

 

 

 

 

walk up to

 

m

 

 

 

 

 

work below shoulder height

 

 

 

 

 

The worker’s incapacity is no longer a result of the injury.

 

5. REASON FOR CAPACITY/INCAPACITY

Please outline your clinical reason for the worker’s capacity/incapacity:

 

 

 

 

 

 

 

 

 

 

6. MEDICAL PRACTITIONER’S DETAILS

Name

 

AHPRA no. MED

 

 

 

 

 

 

 

 

 

 

 

Address

 

Email

 

 

 

 

 

Signature

 

 

 

 

Phone

 

 

 

 

Fax

 

Date

/ /

 

(Practice stamp — optional)

[Form 4 inserted: Gazette 25 Mar 2014 p. 824-5.]

Form 4A

[r. 7A]

Workers’ Compensation and Injury Management Act 1981

(Section 61(1))

PROGRESS CERTIFICATE OF CAPACITY

1. WORKER’S DETAILS

First name

 

Last name

 

 

 

Date of birth

/ /

Claim no.

 

 

 

Phone

 

Email

 

 

 

Address

 

 

 

2. EMPLOYER’S DETAILS

Employer’s name

 

Employer’s phone

 

 

 

Employer’s address

 

 

 

3. MEDICAL ASSESSMENT

Date of this assessment

/ /

Date of injury

/ /

 

 

 

Diagnosis

 

 

 

4. PROGRESS REPORT

 

Activities/interventions

Actual outcome (change in symptoms, function, activity and work participation)

Still required?*

 

 

 

 

 

 

Yes

 

No

 

 

 

 

 

 

Yes

 

No

 

 

 

 

 

 

Yes

 

No

 

 

 

 

 

 

Yes

 

No

 

 

 

 

 

 

Yes

 

No

 

 

 

 

 

 

Yes

 

No

 

 

 

* (If management activities/interventions are still required, please also list them in Section 6 “Injury management plan”.)

 

 

Other factors appear to be impacting recovery and return to work.

 

Comment

 

 

 

5. WORK CAPACITY

Worker’s usual duties

 

 

 

Having considered the health benefits of work, I find this worker to have:

 

 

full capacity for work from

/ /

 

 

but requires further treatment