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Safety, Rehabilitation and Compensation Act 1988

Section 34S

 

 

APPROVAL OF FORM OF

APPLICATION FOR APPROVAL AS A

WORKPLACE REHABILITATION PROVIDER

 

 

 

Comcare, pursuant to section 34S of the Safety, Rehabilitation and Compensation Act 1988 (the SRC Act), with effect on and from 1 January 2016 and for the purposes of paragraph 34C (1)(a) of the SRC Act (approved form for Application for Approval as a Workplace Rehabilitation Provider):

 

1. revokes the instrument dated 17 October 2012 registered as instrument F2012L02079 on the Federal Register of Legislative Instruments; and

 

2. approves the attached form (Application for Approval as a Workplace Rehabilitation Provider).

 

 

Dated:  5 November 2015

 

 

The seal of Comcare was affixed 

in the presence of: Lyndall Moore

 

 

 

 

 

 

 

Jennifer Taylor

Chief Executive Officer

 

 

 

 

 

 

 

 

 

Attachment: Form for application for Approval as a Workplace Rehabilitation Provider– 20 pages.

 

 


 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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Application for

Approval as a Workplace Rehabilitation Provider

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

This application will be completed by organisations wishing to apply for an Instrument of Approval as a workplace rehabilitation provider.

 

This application should be read in conjunction with the document “Guide: Nationally Consistent Approval Framework for Workplace Rehabilitation Providers”.

 

 

 

 

 

 


Contents

Introduction

Information to Complete the Application

Application checklist

Part A – Applicant Details

Part B – Conforming to the Conditions of Approval

Part C- Comcare Specific Information

Appendix 1 – Staff Details

Appendix 2 – Statement of Commitment to the Conditions of

Approval

Appendix 3 – Statement of Commitment to the Code of Conduct for Workplace Rehabilitation Providers

Appendix 4- Comcare Agreement and Authorisation

OFFICE USE ONLY

 

 

 

 


Introduction

 

The Heads of Workers Compensation Authorities (HWCA) endorsed a nationally consistent framework for the approval of workplace rehabilitation providers which commenced on 1 July 2010. Refer to the HWCA document “Guide: Nationally Consistent Approval Framework for Workplace Rehabilitation Providers”. Comcare’s criteria and operational standards reflect this Guide, and are set out in the legislative instrument Criteria and Operational Standards 2015.

 

Organisations should ensure they fully understand the framework contained in the Guide and the Criteria and Operational Standards 2015 prior to making an application to become a workplace rehabilitation provider.

 

 

  1. A completed application must be submitted using this application template to the workers compensation authority in the jurisdiction where approval is sought and be accompanied by the prescribed fee, where appropriate.
  2. Applicants should refer to the Comcare website to confirm the email and/or address details where the application must be lodged.
  3. Applicants should ensure their application contains sufficient information and supporting documentation to demonstrate that the organisation meets the criteria for approval and is able to comply with the operational standards. This will help demonstrate the applicant’s capacity to meet the Conditions of Approval (see the Guide, Section 6 – Conditions of Approval).
  4. Comcare will approve an application where it is satisfied that the applicant meets the criteria for approval and is likely to be able to comply with the operational standards.  Comcare will inform the applicant of its decision by issuing an Instrument of Approval for a maximum 3-year period.
  5. An Instrument of Approval is issued for a maximum period of 3 years, until 30 June of the third year. In order to continue to provide services beyond this date a workplace rehabilitation provider will be required to make a renewal application within the third year as prescribed by the workers compensation authority where renewal of approval is sought.
  6. During the 3-year approval period, the workplace rehabilitation provider will participate in annual self-evaluations and any independent evaluation as required by the workers compensation authority to determine conformance with the criteria for approval and the operational standards.
  7. Should an application not conform to all the criteria and operational standards, the applicant will be given an opportunity to provide further information. Subsequent to this, if the applicant still does not conform to the criteria for approval or is unlikely to meet all of the operational standards, then the application is considered to be unsuccessful.
  8. If an application is unsuccessful, the applicant will be advised of the reasons and the Comcare appeals process.
  9. An organisation that has been unsuccessful in their application will not be eligible to apply for approval until they can demonstrate to the workers compensation authority’s satisfaction that the reasons for non-approval no longer exist.
  10. The provision of false or misleading information is a serious offence and will nullify the Instrument of Approval and this application.
  11. Details regarding submission of the application to Comcare are available on the website at www.comcare.gov.au or by contacting Comcare on 1300 366 979.

 


While considering an application, Comcare may at any time request further information in writing from the organisation and may liaise with other workers compensation authorities where the provider delivers workplace rehabilitation services to exchange information about the application.

Incomplete applications will be returned to the provider.

If there is insufficient space on the application form to complete a response, attach additional information identifying the question to which the response relates.

 

Please ensure you have completed the following sections:

o  PART A - business ownership details including association or connection with other organisations which supply services within the workers compensation industry

o  PART B - Documentation demonstrating conformance with the Conditions of Approval

o  PART C – Comcare Specific information

o Appendix 1 - A signed Statement of Commitment to the Conditions of Approval

o  Appendix 2 - A signed Statement of Commitment to the Code of Conduct for Workplace Rehabilitation Providers

o  Appendix 3- Current staff details completed for each site, where workplace rehabilitation services intend to be delivered (one sheet per site)

o  Appendix 4- Comcare Agreement and Authorisation

o  Payment of the prescribed fee.

 


Part A – Applicant Details

Name of the workers compensation authority where this application is being submitted to:

COMCARE

 

Organisation details

Full name of organisation: 

Trading name of organisation:

Nature of Organisation:

 (Company, Partnership, Sole trader or Individual subsidiary of a Government body)

Name of Principal/s:

ABN/ ACN (if applicable):

 (Attach copy of the ABN record from the Australian Business Registry)

Organisation address: 

State:      

Postcode:     

Postal address: 

State:      

Postcode:      

Phone:

Mobile:

Email:

Name of parent organisation (if applicable): 

Address of parent organisation:

 

State:      

Postcode:     

Name and position of person/s authorised to sign this application on behalf of the organisation:

Name:                                                                                                             Title: 

Name:                                                                                                             Title:

 

 

Application contact person

Name:

Title:

Phone:      

Mobile:

Email:      

 

 

 

Name of person/s who meet the organisational management structure requirements as outlined in Section 2.2, Principle Two: Organisational & administrative arrangements in particular sub-principle 2.5 of this form.

Name/s:   

 

 

Titles: 

 

 

Qualifications and workplace rehabilitation experience of the person/s meeting this requirement

 

 

 

 

Phone:

 

Email:

 

Other workers compensation authorities where approval has been granted

List the jurisdictions in which the applicant has a current Instrument of Approval.

 

 

Referees

Provide the contact details of two referees who can attest to your organisation’s suitability as a workplace rehabilitation provider organisation including statements as to the professional integrity, honesty and due diligence of your organisation’s owner/s and/or management.

 

Name:           

Title:   

Phone:         

Email:      

 

Name:           

Title:   

Phone:         

Email:      

 

Previous Applications

Has your organisation, any of its owner/s and/or management and/or any persons employed or engaged to deliver workplace rehabilitation services by your organisation been refused approval as a provider of rehabilitation services or had approval been withdrawn as a provider of rehabilitation services in any Australian workers’ compensation jurisdictions?

  Yes / No

If so, provide details of the circumstances and reasons why there is no cause to reject your organisation’s application.  These details should state whether the refused approval was associated with:

  1. Your organisation, or
  2. Any of its owner/s, or
  3. Any of its management, or
  4. Any of its employees including contractors and staff.

 

Conflict of Interest

Detail all your organisation’s business affiliations with other suppliers of services within any of the workers compensation authorities and how you will manage any actual or perceived conflict of interest.

 

 

 

Professional misconduct or criminal proceedings

 

Outline if any proceedings have been taken (or are pending) against any of the following, in relation to professional misconduct or criminal proceedings, breaches of the privacy act or financial administration acts.  If so, provide details of the circumstances and reasons why there is no cause to reject your organisation’s application.  These details should state whether the circumstances and reasons was associated with:

  1. Your organisation, or
  2. Any of its owner/s, or
  3. Any of its management, or
  4. Any of its employees including contractors and staff.

 

 

Insurance Documents as outlined in Section 2.2, Principle Two: Organisational & administrative arrangements in particular sub-principle 2.1 of this form.

In the context of workplace rehabilitation service provision, please attach copies of your organisation’s:

 

Professional Indemnity Insurance- Please detail -  Policy number-          Expiry date           Amount      

 

Public Liability Insurance-      Please detail -             Policy number-          Expiry date          Amount      

 

Workers Compensation Insurance- Please detail-  Policy number-          Expiry date          Amount      

 

 

 


Part B – Conforming to the Conditions of Approval

An application must demonstrate how the applicant will conform to the Conditions of Approval.

 

Providers deliver services to workers and employers in a cost effective, timely and proactive manner to achieve a safe and durable return to work.

 

Principle One: Service provision

1.1 A focus on recovery at, or return to work

 

  1. Expectations that a SMART return to work goal, and the services required, are established with relevant parties at the commencement and throughout service provision (relevant parties include worker, employer, insurer and other service providers).
  2. Appropriate services are identified and delivered to maximise recovery at, or return to work.
  3. Services focus initially on recovery at work in the worker’s pre-injury employment or, if that is not possible, return to work with another employer.

 

Provide a succinct statement on what this means to your organisation and how you will apply this principle and its indicators.  For example consider what would you say to an injured worker or an employer about what this means and what will occur.

 

 

 

1.2 The right services provided at the right time

 

  1. Workers receive prompt attention and intervention appropriate to their needs.
  2. Barriers, risks and strengths are identified and strategies promptly implemented.
  3. Intervention is actively coordinated and integrated with other injury management and recovery at, return to work activities.

 

Provide a succinct statement on what this means to your organisation and how you will apply this principle and its indicators. For example consider what would you say to an injured worker or an employer about what this means and what will occur. 

 

 

 

1.3 Effective service provision at an appropriate cost

  1. Needs of the worker and employer are identified by means of adequate and appropriate assessment.
  2. Service levels match the worker and employer needs.
  3. Service costs match the range and extent of service provision.

Provide a succinct statement on what this means to your organisation and how you will apply this principle and its indicators. For example consider what would you say to an injured worker or an employer about what this means and what will occur. 

 

 

 

 

 

 

1.4 Effective communication with all the relevant parties

  1. Respectful, open and effective working relationships established and maintained with and between workers and employers and other relevant parties.
  2. The provider acts as the link between treatment providers and the workplace to translate functional gains into meaningful work activity.
  3. Progress towards the recovery at, or return to work goal is communicated to interested parties throughout service provision.
  4. Durability of employment is confirmed 13 weeks after placement.

Provide a succinct statement on what this means to your organisation and how you will apply this principle and its indicators. For example consider what would you say to an injured worker or an employer about what this means and what will occur. 

 

 

1.5 Evidence based decisions

 

  1. Assessments demonstrate the need for intervention and appropriateness of the recovery at, or return to work strategies.
  2. The extent of workplace rehabilitation intervention and/ or the type of service selected is the most appropriate and cost effective of those available to achieve the recovery at, return to work goal.
  3. An equitable and consistently applied approach to recommending commencement and cessation of service delivery is undertaken.
  4. Consideration is given to workplace industrial relations and human resource matters that may affect the worker’s recovery at, or return to work.

Provide a succinct statement on what this means to your organisation and how you will apply this principle and its indicators. For example consider what would you say to an injured worker or an employer about what this means and what will occur. 

 

 

Principle Two: Organisational and Administrative arrangements

2.1 Comprehensive and robust corporate governance infrastructure

 

  1. Systems of probity that avoid conflict of interest as well as prevent, manage and report malpractice/fraud.
  2. Appropriate financial administration including accurate accounting.
  3. Maintenance of appropriate and adequate insurances, including professional indemnity, public liability and workers compensation.
  4. Data collection, analysis and reporting of provider performance including recovery at, or return to work status and durable return to work rates.

Provide a succinct statement on what this means to your organisation and how you meet and will apply this principle and its indicators.

 

 

2.2 A records management system meeting State and Commonwealth legislation requirements

  1. Comprehensive, accurate and accessible records pertaining to all clients, staff and business operations.
  2. Security of storage of records in accordance with legislative requirements.

Provide a succinct statement on how you meet and will apply this principle and its indicators.

 

 

2.3 Privacy and confidentiality practices meeting relevant privacy legislation requirements

Systems that incorporate privacy and confidentiality requirements within all aspects of the organisational and administrative arrangements.

Provide a succinct statement on what this means to your organisation and how you meet and will apply this principle and its indicators.

 

 

2.4 Safe work practices as well as return to work and injury management policies

  1. Systems that comply with relevant injury management and workers compensation legislation.
  2. Systems that comply with local workplace health and safety legislation.

Provide a succinct statement on what this means to your organisation and how you meet and will apply this principle and its indicators.

 

2.5 Organisational management structure requirements

  1. At least one person in the management structure with a qualification recognised as being sufficient to satisfy the requirements of a Workplace Rehabilitation Consultant and who is able to demonstrate at least five year’s relevant workplace rehabilitation experience (also refer to 4.1.a. Minimum Workplace Rehabilitation Consultant qualifications).

Provide a certified copy of the qualifications and experience of the personnel who meet and will continue to meet this condition.

 

 

Principle Three: Quality Assurance and Continuous Improvement

3.1 Quality Model

  1. Quality systems that ensure customer focused service delivery, and collect, analyse and monitor qualitative and quantitative data to identify areas of strength and opportunities for systems and service improvement.

Provide a succinct statement on what this means to your organisation and how you meet and will apply this principle and its indicators.

 

 

3.2 Quality Assurance

  1. Implementation of appropriate review mechanisms (e.g. annual self evaluations and internal peer reviews) to assure conformance with the Conditions of Approval.
  2. Implementation and documentation of corrective and preventative actions and monitoring and review of their effectiveness.

Provide a succinct statement on what this means to your organisation and how you meet and will apply this principle and its indicators.

 

 

 

 

 

3.3 Customer focus

  1. System to collect, review, analyse and action solicited and unsolicited feedback from customers.
  2. Implementation of an effective complaints management system.

Provide a succinct statement on what this means to your organisation and how you meet and will apply this principle and its indicators.

 

 

3.4 Continuous improvement.

Systems for analysing information and data to identify opportunities for improvement.

Planning, piloting, refining and implementing improvement strategies.

Monitoring and review the effectiveness of any improvement strategies.

Provide a succinct statement on what this means to your organisation and how you meet and will apply this principle and its indicators.

 

 

Principle Four: Staff Management

4.1    Qualifications, knowledge and experience

 

Systems for ensuring that workplace rehabilitation consultants have the minimum qualifications (as outlined below) and the qualifications are verified.

 

Workplace Rehabilitation Consultants will have a qualification recognised, accredited or registered by one of the following associations or Australian Health Practitioner Regulation Agency registration boards (however described):

  • Rehabilitation Counsellor –Australian Society of Rehabilitation Counsellors (recognised),Rehabilitation Counselling Association of Australia (recognised)
  • Occupational Therapist (registered)
  • Physiotherapist (registered)
  • Exercise Physiologist -Exercise and Sports Science Australia (accredited as an Exercise Physiologist)
  • Psychologist (registered)
  • Speech Pathologist - Speech Pathology Australia (recognised)
  • Social Worker- Australian Association of Social Workers (recognised)
  • Medical Practitioner (registered)
  • Nurse (registered)

 

Note 1: A workplace rehabilitation consultant will be taken to satisfy 4.1 if they will be eligible for full membership on completion of a current period of required supervised professional practice (as determined by the relevant Professional Association or Registration board).

 

Note 2: ASORC’s Affiliate category of membership does not meet the minimum qualifications to work as a workplace rehabilitation consultant. However some jurisdictions recognise ASORC’s Affiliate category of membership as a pathway towards meeting the minimum qualifications and as such allow Affiliate members to work in the industry under the supervision of a workplace rehabilitation consultant. Workplace rehabilitation providers should check with the local workers compensation authority as to their position of ASORC Affiliate membership.

 

AND 12 months or more experience delivering workplace rehabilitation services.

 

Where workplace rehabilitation consultants have less than 12 months’ experience delivering workplace rehabilitation services, a comprehensive induction program will be completed and professional supervision provided for at least 12 months.

 

Note 3: Some workplace rehabilitation services can only be delivered by designated professional groups. The minimum qualifications to deliver these services are included in the description of the workplace rehabilitation services as specified by each jurisdiction.

 

Your organisation must provide a completed Staff Details sheet - for each location being proposed as part of this application (see Appendix 1- Staff details)).  Provide a succinct statement on what this means to your organisation and how you will apply this principle with particular reference made to the Qualification, knowledge and experience sub principles b. c. and d.

 

 

4.2 Induction, ongoing learning and development

  1. A robust induction and continuous learning and development program to support the acquisition and maintenance of staff skills and knowledge.
  2. Staff have access to and understand all current policies and procedures relevant to their work.
  3. Staff having appropriate supervision and support and participate in internal peer review processes.
  4. Staff members are compliant with the professional code of conduct relevant to their particular qualification.

Provide a succinct statement on what this means to your organisation and how you meet and will apply this principle and its indicators.

 

 

 

4.3 Adequate staff resourcing

  1. Caseload management systems that efficiently allocate cases to staff with the experience and skill level to match the worker’s injury, needs and potential case complexity.
  2. Handover practices where cases are reviewed and all relevant parties informed to maintain continuity of care for the worker.

Provide a succinct statement on what this means to your organisation and how you meet and will apply this principle and its indicators.

 

 

2. Provider Annual Self-evaluations and other Evaluations as required

To demonstrate ongoing conformance with the Conditions of Approval, an organisation must participate in annual self-evaluations and any independent evaluations as required by the workers’ compensation authority.

 

Outline the annual self-evaluation procedures and processes that will be implemented in the context of your organisation’s quality assurance model. Confirm your organisation’s agreement to conduct annual self-evaluations.

 

Please outline how the organisation will ensure that the person(s) who will conduct the provider annual self-evaluations on behalf of the organisation, meet the requirements of an independent evaluator including their qualifications. Please confirm what steps will be taken to ensure they will not personally be responsible for the aspects of the business that they evaluate. Confirm your organisation’s agreement to participate in independent evaluations as required by the workers’ compensation authority.

An organisation must demonstrate management of 12 cases (excludes assessment only cases) of activity consistent with the model of workplace rehabilitation within any workers compensation jurisdiction. (Due consideration will be given to organisations servicing rural and remote areas).

 

Outline how your organisation will meet this condition. 

If your organisation is currently approved as a provider of workplace rehabilitation services for a workers’ compensation authority, please attach current case data to illustrate conformance with this requirement at this time.

 

 

 

The workplace rehabilitation provider must maintain the minimum return to work rate as set by the workers’ compensation authority.

 

Outline how your organisation will meet and maintain the minimum return to work rate. 

If your organisation is currently approved as a provider of workplace rehabilitation services for a workers’ compensation authority, please attach current performance data to illustrate what return to work rates are being achieved at this time.

 

 

 

The workplace rehabilitation provider’s facilities at all locations where services are intended to be provided must provide an accessible and appropriate environment for workers, staff and visitors and comply with local workplace health and safety legislation.

 

List each location/site.

For each location/site describe how the facilities are accessible and appropriate for all workers, staff and visitors.  In your response detail:

 

For each location/site describe how the facilities comply with local workplace health and safety legislation.

 

 

Part C- Comcare Specific Information

 

 

Provide a reference from an independent, qualified person, such as accountant or bank manager, to attest to the financial viability of the applicant.

 

Please attach document.

 

 

 

 

 

Please list the services provided by your organisation.

 

 

 

 

 

 

Please attach copies of sample workplace rehabilitation reports (de-identified).

 

 

 

 

 

Where the provider holds approval in another state/territory workers compensation jurisdiction they must maintain the minimum applicable RTW rates. 

Please provide a summary of the types of referrals managed and the outcomes achieved for work undertaken in other jurisdictions, and where possible grouped according to the following claims duration cohorts (claims duration- 0-6 months, 6-18 months, greater than 18 months) indicating the following:

 

  1. annual number of referrals
  2. number of files closed with a RTW outcome
  3. number of files closed without a RTW outcome
  4. number of current cases

 

 

Appendix 1 – Staff Details

ORGANISATION:____________________________________________________________________________________________________________

ADDRESS*:________________________________________________________________________________________________________________

SITE OR PROVIDER APPROVAL NUMBER, IF APPLICABLE: ____________________________________________ DETAILS AS AT DATE: ______________

 

Name and position title

Qualifications

Include qualification, institution, year of concurrence

Years of workplace rehabilitation experience

Basis of employment (e.g. fee-for-service, part time or full time)

Professional membership or registration (type and membership number)

Supervision arrangement for staff with less than 12 months experience

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

* Duplicate this page and table for each location in the jurisdiction where the application is submitted. Add more rows to this table if needed to list all staff members.

Appendix 2 – Statement of Commitment to the Conditions of  

                          Approval

A reference to the Workers Compensation Authority is a reference to the Workers Compensation Authority who issued the Instrument of Approval.

The Conditions of Approval are:

1.   The workplace rehabilitation provider must comply with the Principles of Workplace Rehabilitation.

2.   The workplace rehabilitation provider must ensure that all services are delivered in accordance with the workplace rehabilitation model by persons who hold the minimum qualifications as defined in the Principles of Workplace Rehabilitation and in accordance with service descriptions appropriate to the Workers Compensation Authority where the approval is being sought.

3.   The workplace rehabilitation provider’s management structure must include at least one person who holds a rehabilitation consultant qualification outlined in the Principles of Workplace Rehabilitation and who is able to demonstrate five years relevant workplace rehabilitation experience.

4.   The workplace rehabilitation provider must participate in annual self-evaluations and in independent evaluations as required by the Workers Compensation Authority to demonstrate conformance with the Conditions of Approval.

5.   The workplace rehabilitation provider must demonstrate management of 12 cases (excludes assessment only cases) of workplace rehabilitation within any workers compensation jurisdiction for each 12 month period within the three year approval period. (Due consideration will be given to providers servicing rural and remote areas).

6.   The workplace rehabilitation provider must maintain the minimum return to work rate as set by the Workers Compensation Authority.

7.   The workplace rehabilitation provider must provide data to the Workers Compensation Authority consistent with the Conditions of Approval.

8.   The workplace rehabilitation provider must deliver services in compliance to the Code of Conduct for Workplace Rehabilitation Providers.

9.   The workplace rehabilitation provider’s facilities at all locations where services are delivered must provide an accessible and appropriate environment for workers, staff and visitors and comply with local workplace health and safety legislation.

10. The workplace rehabilitation provider must remain financially solvent.

11. The workplace rehabilitation provider must notify the Workers Compensation Authority in advance, or as soon as practical, if any of the following situations arise and accept that the Workers Compensation Authority will review the status of approval and determine whether the proposed arrangements conform with the Conditions of Approval:

i. the business is sold or the controlling interest in the business is taken over by a new shareholder(s), owner(s) or director(s).

ii. the business changes its trading name or location of premises.

iii. the business supplies or has connections with other suppliers of services within the   workers compensation industry.

iv. a new chief executive officer or director or head of management is appointed.

v. there is a major change in the service delivery model and/or staff which may impact on the delivery of workplace rehabilitation services.

vi. there is any other change that affects, or may affect, the provider’s service quality and procedures.

vii. the provider has entered into voluntary financial administration, becomes insolvent or is the subject of bankruptcy proceedings.

viii. there is any professional misconduct proceedings being taken against the provider or any individuals employed or engaged by the provider.

 

12. The workplace rehabilitation provider must accept that the Workers Compensation Authority may:

i. initiate an independent evaluation at any time during the period of the approval which may involve an evaluation of conformance to the Conditions of Approval

ii. consult with the relevant professional or industry associations in determining what are reasonable expectations regarding performance

iii. impose additional requirements

iv. exchange information with other Workers’ Compensation Authorities on provider performance

v. cancel approval status if the above conditions are not met.

I/We have read, understand and accept that I/we must meet and continue to conform to the Conditions of Approval and give consent for sharing of information in relation to this application and the ongoing approval.

I/We understand and are aware that any breach with the terms and conditions of the Conditions of Approval may nullify any application or Instrument of Approval issued by the Workers Compensation Authority in the event the application is approved.

To be signed by the person/s who is/are authorised to sign this application on behalf of the organisation seeking approval as a workplace rehabilitation provider.

 

Organisation name:

     

  

Name and title of authorised signatory:

     

Signature of authorised signatory:

                                                                                                                        Date:       /       /      

 

Name and title of authorised signatory:

     

Signature of authorised signatory:

                                                                                                                        Date:       /       /      

 


Appendix 3 – Statement of Commitment to the Code of Conduct for Workplace Rehabilitation Providers

 

I/We have read and agree to conform to the Code of Conduct for Workplace Rehabilitation Providers if approved as a workplace rehabilitation provider.

I/We understand and are aware that any breach of the Code of Conduct for Workplace Rehabilitation Providers may nullify any Instrument of Approval issued by the Workers Compensation Authority in the event the application is approved.

To be signed by the person/s who is/are authorised to sign this application on behalf of the organisation seeking approval as a workplace rehabilitation provider.

Organisation name:

     

  

Name and title of authorised signatory:

     

Signature of authorised signatory:

                                                                                                                                            Date:       /       /      

 

Name and title of authorised signatory:

     

Signature of authorised signatory:

                                                                                                                                           Date:       /       /      

 


Appendix 4- Comcare Agreement and Authorisation

Organisation name:

     

 

On behalf of the applicant:

1)  I/We certify that the information provided in this application and in support of the application is true and correct. I understand that giving false or misleading information is a serious offence under the Criminal Code;

2)  I/We agree to advise Comcare as soon as possible of any changes to the information provided in this application; and

3)  I/We authorise relevant persons to provide to Comcare personal information in relation to this application and for the purposes of enabling Comcare to determine whether the applicant, a relevant principal or employee of the applicant is complying with the criteria and operational standards for workplace rehabilitation providers determined under sections 34D and 34E of the SRC Act. In particular, I understand that this authorises Comcare to seek confirmation of the qualifications, probity and financial standing of the applicant, relevant principals and any workplace rehabilitation provider engaged or employed and the likely effectiveness, availability and cost of the rehabilitation programs which may be provided by the applicant.

If the applicant is approved as a workplace rehabilitation provider, I/We :

4)  understand that failure to comply with the criteria and operational standards for workplace rehabilitation providers  determined under sections 34D and 34E of the SRC Act may result in the revocation of approval under section 34Q of that Act;

5) understand that failure to comply with the any condition(s) specified in the instrument of approval may result in the revocation of approval under section 34Q of the SRC Act;

6)  agree to advise Comcare in writing within one month of any changes in workplace rehabilitation providers employed or engaged by the applicant to manage return to work plans under the SRC Act, including evidence of qualifications, experience/supervision arrangements and training (including attendance at Comcare rehabilitation provider training); and

7)  agree to Comcare listing the applicant’s name, service delivery description and contact details on Comcare’s website.

 

Name and title of authorised signatory:

     

Signature of authorised signatory:

                                                                                                                                           Date:       /       /      

 

 

Name and title of authorised signatory:

     

Signature of authorised signatory:

                                                                                                                                           Date:       /       /      

 


 

OFFICE USE ONLY

Received Via:   Mail / Counter /

                                Fax / Email

Date received:      /     /     

File reference:      

Processed By:     

Authorised By:     

Instrument of Approval Issued:

 

o Yes                         o No

 

Date of issue:      /     /     

 

APPLICATION REQUIREMENTS

Application fee (if applicable)

o Yes

o No

PART A- Applicant details

Home jurisdiction specified

o Yes

o No

Applicant details content

o Yes

o No

Professional indemnity policy details

o Yes

o No

Public Liability policy details

o Yes

o No

Workers’ compensation policy details

o Yes

o No

PART B- Conforming to the Conditions Of Approval

Documentation provided to demonstrate how applicant will conform to Conditions of Approval

o Yes

o NA

o No

Cases of Workplace Rehabilitation Activity (12 cases per year) (if applicable)

o Yes

o NA

o No

Current RTW data (if applicable)

o Yes

o NA

o No

ATTACHED DOCUMENTS

PART A

Copy of ABN/ ACN

o Yes

o No

Copy of other Workers Compensation Authority (WCA)

Instrument of Approval (if applicable)

o Yes

o No

PART B

Appendix 1 – Completed staff details sheet/s

o Yes

o No

Appendix 2 – Statement of commitment to Conditions of Approval signed

o Yes

o No

Appendix 3 – Statement of Commitment to the Code of Conduct signed

o Yes

o No

Other documents as requested by the WCA

o Yes

o No

PART C-

 

 

Comcare specific information

o Yes

o No

Appendix 4- Comcare Agreement and Authorisation

o Yes

o No