The following workers’ compensation and injury management forms and templates are available to employers.
Injury management & return to work- Template Injury Management System (Word – 52kb) This template will assist employers to devise an appropriate injury management system for their workplace.
- Template Return to Work Program (Word – 108kb) This template will assist employers to devise an appropriate Return to Work Program in collaboratively with the injured worker.
- Workplace Rehabilitation Referral Form (Word – 200kb) This referral form can be used to refer an injured worker for workplace rehabilitation services. Workplace rehabilitation providers can assist injured workers to return to work in a timely and appropriate fashion.
- Form 18: Notice of Arrangement of Audiometric Test (Word – 308kb)
This form is used when notifying a worker to submit to an arranged audiometric test.
- Form 21: Notice of Dispute (noise induced hearing loss) (Word – 121kb)
This form can be used by workers or employers when disputing the results of an audiometric (hearing) test.
- Form 407: Noise Induced Hearing Loss Audiometer Calibration (Word – 94kb)
This form certifies that an audiometer has been calibrated in a WorkCover WA approved calibration laboratory.
- Form 408: Noise Induced Hearing Loss Audiometric Booth Assessment (Word – 131 kb)
This form is used during an audiometric booth assessment. It is the booth owner’s responsibility to submit the original copy to WorkCover WA in order for approval of the booth to be granted.
- Notice of Intention to Dismiss a Worker (Regulated Form 15G) (PDF – 270kb)
This form is required if you intend to dismiss an injured worker within 12 months from the day the worker is entitled to receive weekly payments.
Particular forms are required throughout the dispute resolution process.
Conciliation
Forms required for the Workers’ Compensation Conciliation Service are available from the Conciliation rules and forms page.
Arbitration
Forms required for the Workers’ Compensation Arbitration Service are available from the Arbitration rules and forms page.
General forms
Regulated forms, and guides for completing them, are available on the Regulated forms page.
