WIXLIB

REHABILITATION PROGRAMUnder section 37 of the Safety, Rehabilitation and Compensation Act 1988INFORMATION FOR EMPLOYEESAbout your rehabilitation programWhat if I don’t agree with adetermination made by thedelegate?Your rehabilitation program sets out the details of serviceand activities to assist you in your rehabilitation. Itshould be developed in consultation with you and yourCase Manager, and may involve discussion with yoursupervisor, your treating doctor and if relevant yourapproved workplace rehabilitation provider (WRP). Itcontains goals or rehabilitation objectives, and detailscosts, time and actions considered necessary to achievethese goals or objectives.If you do not agree with the determination made bythe delegate (usually the Case Manager) you may askComcare to reconsider the determination that you undertakea rehabilitation program. Comcare will then consider theinformation available and will decide to affirm, revoke orvary the delegate’s decision.Your rehabilitation program—when signed by the person(usually the Case Manager) who holds a delegation undersection 41A of the Safety, Rehabilitation and CompensationAct 1988 (SRC Act) to arrange your rehabilitation—constitutes a decision under s. 37 of the SRC Act 1988.If you have any concerns or experience difficultiesundertaking your rehabilitation program speak with yourCase Manager or WRP as soon as possible.You must provide the following information to Comcarewithin 30 days of receiving the determination:If you are satisfied with the rehabilitation program, youshould sign it and your Case Manager will give you a copy.To request a reconsideration of yourrehabilitation program a copy of the rehabilitation program a written request for a reconsideration explaining whyyou don’t agree with the determination any new information that supports your request, suchas medical reports that have not previously beenconsidered.Send the information to:Disputed ClaimsComcareGPO Box 9905Canberra ACT 2601Team.Reconsiderations@comcare.gov.auNOTICE OF RIGHTS ANDRESPONSIBILITIESWhat is a determination?A determination is a decision—in this case, a decisionmade concerning the details of your rehabilitation programby the delegate (usually a Case Manager) under section 37of the SRC Act 1988. Section 37 of the SRC Act 1988 setsout the matters your delegate should have considered inmaking the determination. These details are also providedon the signature page of this form.30 day limitIf you are unable to put your request to Comcare within30 days, you may apply for an extension of time.GPO BOX 9905 CANBERRA 2601 1300 366 979 COMCARE.GOV.AUSRC 040 July 2021Page 1 of 6

What happens next?Your employer will receive a copy of your request forreconsideration and may provide a response. Comcarewill consider the information available and will decideto affirm, revoke or vary the determination.What are your responsibilities?You are to: actively participate in any rehabilitation programdeveloped by your Case Manager or WRP inconsultation with you; implement any recommended and agreed changes toyour work practices, workplace environment and/orhome environment in consultation with your employerto minimise the chance of further injuries or accidents.What if I do not participate fully inthe rehabilitation program?If you refuse or fail, without reasonable excuse, toparticipate in the rehabilitation program provided by youremployer, your rights to compensation entitlements underthe SRC Act 1988 (excluding medical treatment costs), andyour right to institute or continue any proceedings underthe SRC Act 1988 will be suspended until you participatein the rehabilitation program. This means you cannotclaim retrospective compensation entitlements (excludingmedical treatment costs) for the period of that suspension.Entitlements can only be reinstated on and from the dateupon which you recommence participation in your agreedrehabilitation program (see ss. 37(8) of the SRC Act 1988).Note: If you decide to have a solicitor help you withthis process, any legal costs will be your responsibilityregardless of the outcome of Comcare’s decision.Privacy informationYour privacy is important to Comcare. We will only collect,use or disclose your personal information in accordancewith the Privacy Act 1988 and in connection with ourfunctions under the Safety, Rehabilitation and CompensationAct 1988 (SRC Act). Comcare is collecting the informationyou provide in this form to perform claims managementand rehabilitation facilitation functions in accordance withthe SRC Act. Comcare may also use and disclose yourpersonal information for these purposes, including to yourWRP or your employer. If Comcare is unable to collect yourinformation for these purposes, Comcare may not be ableto take action on your claim.If your rehabilitation is managed by a WorkplaceRehabilitation Provider (WRP), Comcare will also collectinformation about your rehabilitation program from yourWRP. This may occur after you make complaints to WRPsor their Consultants about their delivery of services, andwhen your rehabilitation program is finalised. Comcarewill collect this information to facilitate monitoring of WRPperformance and compliance with their conditions ofapproval to provide services to you, in line with Comcare’sWRP approval functions under the SRC Act. Comcare mayalso use and disclose your personal information for thispurpose. Your rehabilitation program will not be impacted ifyou do not provide your personal information to Comcare.Comcare is unlikely to disclose your personal informationto overseas recipients.For a copy of Comcare’s Privacy Policy, to request accessto or a change of your personal information or to make aprivacy complaint please refer to comcare.gov.au/privacy.You can also contact us on 1300 366 979 or email us atprivacy@comcare.gov.au.What if I want copies of documentsheld on my files?You can write to Comcare requesting the documents youneed held by Comcare.Requests for information held by your employer or WRPshould be directed to them.More informationIf you need any further information about your rightsor other specific issues, please contact Comcare on1300 366 979. You can also make an online enquiryor access resources via the Comcare websitewww.comcare.gov.au.You can provide feedback or raise concerns aboutyour workplace rehabilitation provider to Comcareat rehab.approval@comcare.gov.au or call us on1300 366 979.SRC 040 July 2021Page 2 of 6

Employee detailsSurnameGiven name(s)/Date of birth/Comcare claim numberEmployee’s pre-injury occupationCompensable conditionDate of injury////////Nature of injuryEmployee’s current work statusAt work:Was a s36 assessment completedpre-injury statusSreduced hoursRmodified dutiesMboth reduced and modifiedBNot at work sinceEmployment ceased////NoReasonYeswhen//(Please attach to this form)XCType of rehabilitation programReturn to workRedeploymentReferral dateMaintain at workNon return to workRehabilitation program start dateNon-return to work rehabilitation program goal(s)Expected rehabilitation program end dateMedical restrictionsEmployer detailsCase Manager’s detailsName of employerWork phoneCase Manager’s nameEmailWhere a workplace rehabilitation provider (WRP) is being used complete the following detailsWRP contact detailsName of organisationPhoneComcare provider numberFaxWRP consultantEmailI determine that no rehabilitation program is required at this time, for the following reasonsDelegate’s signatureNote: By signing here you are making a determination under section 37 not to provide a rehabilitation program at this time.SRC 040 July 2021Page 3 of 6

REHABILITATION PROGRAM—SERVICE DETAILSEmployee’s nameComcare claim numberInterim goal (RTW) in terms of workplace, duties and hoursFinal goal (RTW) in terms of workplace, duties and hoursMust be completed/Expected final goal commencement dateEmployer SameSNewNDutiesSameSNewN ModifiedHoursSameSReducedMREmployer SameSNewNDutiesSameSNewN ModifiedHoursSameSReduced/MRNot applicable (Non-RTW program)Not applicable (Non-RTW program)Describe the interim goal in terms of workplace, duties and hoursDescribe the final goal in terms of workplace, duties and �ActionCase Manager—ActionOutcomes expectedOutcomes expectedOutcomes expectedTarget start dateTarget end date////////////////Target start dateTarget end date////////////////Target start dateTarget end date////////////////SRC 040 July 2021Page 4 of 6

REHABILITATION PROGRAM—SERVICE DETAILSEmployee’s nameComcare claim numberWorkplace rehabilitation provider’s responsibilitiesActionExpected outcomesTarget start dateIs a work trial one of the activities within this rehabilitation program?NoYesHave you attached the signed work trial agreement?NoYesIs a return to work schedule (or similar) attached?NoYesThe Work trial agreement and a work schedule will form part of the determinationTarget end dateService codeHoursCost (GST inclusive)//// //// //// //// //// //// //// //// //// //// //// //// //// //// //// //// //// //// //// //// //// Sub-total for service 92 Sub-total for service 93 Sub total for service 94 Total cost (including GST) SRC 040 July 2021Page 5 of 6

This entire document constitutes a determination undersubsection 37(1) of the SRC Act 1988Delegate to completeIBefore signing, please read the cover page.(holding a delegation), determine under subsection 37(1) ofthe Safety, Rehabilitation and Compensation Act 1988 that theWorkplace rehabilitation provider to completeemployee (being a person who has suffered an injury resulting inI agree to provide this rehabilitation program to the employeerehabilitation program described in this form. The program willnamed, subject to the Comcare standards and criteria forbe provided by (name of workplace rehabilitation provider whereworkplace rehabilitation der’ssignatureIn making my decision I have had regard to subsection 37(3):/Datean incapacity for work or an impairment), should undertake thea) any written assessment given under subsection 36(8);/b) any reduction in the future liability to pay compensation ifthe program is undertaken;Namec) the cost of the program;Titled) any improvement in the employee’s opportunity to beemployed after completing the program;Organisation/Agencye) the likely psychological effect on the employee of notproviding the program;f) the employee’s attitude to the program;Supervisor to completeg) the relative merits of any alternative and appropriaterehabilitation program; andI have been involved in the development of this return to workh) any other relevant matterplan and agree to work with the Case Manager and employee tosupport the return to work process.Evidence of this is demonstrated by:Supervisor’ssignature/Date/NameEmployee to completeI have been involved in the development of this rehabilitationprogram and understand my rights and obligations under theSafety, Rehabilitation and Compensation Act 1988.Signature ofthe delegateEmployee’ssignature/Date//DateNameNameI understand that if I am not satisfied with this determination I mayOrganisation/Agencyrequest a reconsideration by Comcare (see ‘What if I don’t agreewith a determination?’ on page 1).Distribution of copies: EmployeeCase Manager/PositionWRPSupervisorComcareDoctorSRC 040 July 2021004004Page 6 of 6

at rehab.approval@comcare.gov.au or call us on 1300 366 979. SRC 040 July 2021. Page 3 of 6. Employee details. Surname Given name(s) Date of birth / / Comcare claim number Employee's pre-injury occupation Compensable condition Date of injury / / Nature of injury Employee's current work status .