Medical Certificate
For ACT Workers Compensation Claims - to be completed by a Doctor 
AF2002-91
Workers Compensation Act 1951 – Form 1

Injured person's surname/family name	
Given Names	
Date of birth
_________________________________________________________________________________________________________________________
Medical Information
Date of injury	
Date of initial assessment

Please complete the following four categories, with reference to clinical examination, any investigations, and approved medical guidelines or clinically relevant research.

Description of Injury/Aetiology 

Is the injury/disease consistent with the aetiology described by the patient? Yes/No

Diagnosis	

Prognosis	

Treatment	

Note: If this is not the first certificate it is not necessary to complete the above four categories, unless any change has taken place. If there is any change in the four categories in relation to the patient, please state the changes with reference to approved medical guidelines, clinically relevant research and examination or investigations.

Does the aetiology or diagnosis suggest a pre-existing condition or aggravation of pre-existing condition?

Do you consider the person's employment to be a substantial contributing factor to the injury?  Yes/No
____________________________________________________________________________________
Proposed treatment plan
Treatment likely to be required:	Nil/Short Term (< 6 weeks)/Medium Term (6-12 weeks)/Long Term (>12 weeks)

Referred to Specialist		Type	Name of person	Phone/contact details
Referred to Therapy		Type	Name of person	Phone/contact details 
Referred to Other		Type	Name of person	Phone/contact details 

Will the patient be incapacitated for work for a continuous period of longer than 7 days?
If 'Yes' a rehabilitation service will automatically be provided for the patient.

Please indicate the patient's fitness for work.
Fit to resume normal duties on		Fit for modified or other duties on	
Unfit for work from				Date of Next medical assessment	

Medical Practioner’s Information
Name (please print)
Professional qualification
Provider number

Practice name and address/hospital name
Telephone number	

I declare that: I am registered medical practitioner; to the best of my knowledge the information provided here is true and correct; and I am prepared to be my patient's treating doctor for the purposes of the Workers Compensation Act 1951. 

Signature				Date