Work Capacity Certificate - Free Download
4.7, 2572 votes
Please vote for this template if it helps you.
Work Capacity Certificate
Work Capacity Certificate
A. Patient and employer details
Family name:
Claim number (if known):
Date of birth:
B. Injury details and assessment
I examined you on:
for injury(s)/condition(s) you stated occurred/developed on:
The stated cause was:
The injury(s)/condition(s) you presented with is/are consistent with your stated cause(s): Yes No
New condition Recurrence of pre-existing condition
My clinical diagnosis/es based on my examination of you and other available information is:
Other comments/clinical findings:
C. Certification
In my opinion, you: (please tick whichever apply)
have recovered from your injury/condition and are fit to return to your normal duties and hours on:
some further treatment may be required
are fit to perform suitable duties that accommodate your functional abilities from: to
are medically unfit to undertake suitable duties while recovering from your injury for the period: to
Note: Certification based on functional capacity, not available duties.
days weeks OR uncertain at this stage
I estimate you should have functional capacity to return to work in
(estimated timeframe will assist with planning for return to safe work)
I would like to review your progress on:
or at your next medical consultation
D. Treatment plan
The following treatment plan is aimed at assisting your recovery and return to work:
I have referred you for the following clinical treatment:
Medical specialist (Name & specialty)
Psychologist (Name)
Physiotherapist (Name)
Other (Name & discipline)
Work Capacity CertiÓÜúcate
Given names:
Employer name:
Work Capacity Certificate Previous Page
Work Capacity Certificate