Workers Compensation Certificate of Capacity Example
Example document for Workers Compensation Certificate of Capacity. Use this as a reference when creating your own.
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Document: Workers Compensation Certificate of Capacity
Example Document
Last updated 7/29/2026
CERTIFICATE OF CAPACITY
1. WORKER DETAILS
Full Name: John Smith Date of Birth: 15/03/1985 Gender: Male Occupation: Electrician Employer: Sparky Solutions Pty Ltd Date of Injury: 20/10/2023
2. PRACTITIONER DETAILS
Practitioner Name: Dr Sarah Jones Provider Number: 12345678 Practice Name: City Health Medical Address: 100 George Street Suburb: Sydney State: NSW Postcode: 2000 Phone: 02 9000 0000 Date of Consultation: 21/10/2023
3. DIAGNOSIS AND INJURY DETAILS
What is the injury or illness? Acute lumbar sprain.
Date of first consultation for this injury: 21/10/2023
Is this injury related to employment? [X] Yes [ ] No
4. WORK CAPACITY ASSESSMENT
Current Capacity (Tick one box only): [ ] No current work capacity [X] Partial current work capacity [ ] Full current work capacity
If Partial Capacity - Suitable Duties
Please specify the hours the worker can work: 4 hours per day.
What CAN the worker do? [X] Sitting for 30 minutes [ ] Standing for long periods [ ] Walking [X] Lifting up to 5 kg [X] Driving light vehicles [ ] Kneeling [X] Other: Office based administration tasks, answering phones, ordering stock.
What CANNOT the worker do? [X] Heavy lifting (over 5 kg) [X] Repetitive bending [X] Working at heights [X] Operating heavy machinery [X] Other: Climbing ladders, using hand tools for prolonged periods.
5. TREATMENT PLAN
Is further treatment required? [X] Yes [ ] No
Type of treatment: [X] Physiotherapy (2 times per week) [ ] Specialist referral [X] Medication (Anti-inflammatories) [ ] Other: Rest and ice.
Next appointment due: 04/11/2023
6. CERTIFICATION STATEMENT
I certify that the information provided is true and correct to the best of my knowledge.
Practitioner Signature: S. Jones Date: 21/10/2023
Notes
This example shows a partial capacity certificate. The doctor has identified that the worker can still contribute to the business through light duties like administration. The employer can use this to keep John employed at the desk while he recovers, rather than him being off work completely.
About this Example
Part of the Workers Compensation Certificate of Capacity document collection
Document Type
Workers Compensation Certificate of Capacity
A medical form completed by a doctor to detail a worker's injury and their capacity for work. It is required for workers compensation claims in Australia.