CERTIFICATE OF CAPACITY

1. WORKER DETAILS

Full Name: [FULL NAME OF WORKER] Date of Birth: [DD/MM/YYYY] Gender: [Male/Female/Other] Occupation: [JOB TITLE] Employer: [BUSINESS NAME] Date of Injury: [DD/MM/YYYY]

2. PRACTITIONER DETAILS

Practitioner Name: Dr [DOCTOR NAME] Provider Number: [PROVIDER NUMBER] Practice Name: [MEDICAL CENTRE NAME] Address: [STREET ADDRESS] Suburb: [SUBURB] State: [STATE] Postcode: [POSTCODE] Phone: [PHONE NUMBER] Date of Consultation: [DD/MM/YYYY]

3. DIAGNOSIS AND INJURY DETAILS

What is the injury or illness? [DESCRIPTION OF INJURY, E.G. LOWER BACK STRAIN]

Date of first consultation for this injury: [DD/MM/YYYY]

Is this injury related to employment? [ ] Yes [ ] No

4. WORK CAPACITY ASSESSMENT

Current Capacity (Tick one box only): [ ] No current work capacity - The worker cannot perform any work duties. [ ] Partial current work capacity - The worker can perform some work duties with restrictions. [ ] Full current work capacity - The worker can perform their pre-injury duties without restrictions.

If Partial Capacity - Suitable Duties

Please specify the hours the worker can work: [NUMBER] hours per [Day/Week]

What CAN the worker do? [ ] Sitting for [X] minutes [ ] Standing for [X] minutes [ ] Walking [ ] Lifting up to [X] kg [ ] Driving [ ] Kneeling [ ] Other: [DETAILS]

What CANNOT the worker do? [ ] Heavy lifting (over [X] kg) [ ] Repetitive bending [ ] Working at heights [ ] Operating heavy machinery [ ] Other: [DETAILS]

5. TREATMENT PLAN

Is further treatment required? [ ] Yes [ ] No

Type of treatment: [ ] Physiotherapy [ ] Specialist referral [ ] Medication [ ] Other: [DETAILS]

Next appointment due: [DD/MM/YYYY]

6. CERTIFICATION STATEMENT

I certify that the information provided is true and correct to the best of my knowledge.

Practitioner Signature: _______________________ Date: [DD/MM/YYYY]