Form 132A Application for assessment
of permanent impairment

This is an approved form under section 132A of the Workers’ Compensation and Rehabilitation Act 2003

Version 1

Important instructions and privacy statement
·  This form is to be completed where a worker requests a permanent impairment assessment to determine if their injury/ies has resulted in a degree of permanent impairment but has not already made an application for compensation for that injury/ies.
·  This form is not to be completed if the worker has already made an application for compensation of their injury/ies under section 132 of the Workers’ Compensation and Rehabilitation Act 2003.
·  To be eligible to make this application you must have been a worker at the time of the event that resulted in the injury relevant to this application.
·  Your application needs to be accompanied by a Workers’ Compensation Medical Certificate in the approved form.
·  Your application needs to be accompanied by any other evidence or particulars prescribed under regulation 85A. This includes but is not limited to incident/accident reports or other material verifying the event and medical evidence such as medical certificates, radiological reports or other medical reports. If the information required is not provided, the administration of your application may be delayed or it may not be possible to further progress the application.
·  The information collected by this form and throughout the course of your application is collected in accordance with the Workers’ Compensation and Rehabilitation Act 2003 and Workers’ Compensation and Rehabilitation Regulation 2003.
·  The information may be disclosed to the Workers’ Compensation Regulator, medical and allied health providers and other insurers as needed to assess your application.
Please note: If there is insufficient space on the form, you may attach separate sheets. If you attach separate sheets, please ensure they are signed and dated by you as the applicant.

Worker’s details

Title: / Surname:
Given names:
Gender / ð Female / ð Male
Date of birth: / / /

Has the worker ever been known by any other name/s?

Yes ð (if yes, please provide details below) No ð

Title: / Surname:
Given names:
Residential address:
Postal address: / (If same as residential, please write ‘as above’.)
Telephone: / Mobile number:
Email address:

Workers’ employment details at date of event causing injury

Usual occupation:
Full time or Part time
Nature of employment at time of event (if different to usual occupation)

Details of employer at the time of the event causing injury

Employer trading name
Business address: (street address)

Details of other employer at the time of the event causing injury (including self-employment)

Employer’s trading name:
Business street address:
Work telephone: / Mobile:
Email address

Date of the event resulting in the injury

Date of event: / Time of event:
Date of first consultation with medical practitioner about injury

If the event occurred over a period of time:

Date the event period began:
Date the event period ended:
Date the symptoms began:
Date of first consultation with medical practitioner

Exact location where event occurred (e.g. driveway, State Law Building, 50 Ann St Brisbane)

Place:
Street address:

Complete and detailed description of the event resulting in the injury

If more space is required, please attach event description on separate sheet of paper.

Details of all injuries alleged to have been sustained because of the event

Part of body injured (e.g. right index finger, lower back) / Nature of injury/ies (e.g. strain, fracture, crush, burn)

Details of all doctors, hospitals, rehabilitation and any other service providers from whom the worker received treatment for the injury arising from the event

Name of doctor/hospital/provider / Address

Details of employer representative to whom injury was reported

Name:
Position:
Business address:
Telephone: / Mobile:
Email address: / Date reported

Witnesses to the event causing injury

Where there any witnesses to the event?

Yes ð (if yes, please provide their details below) No ð

Witness 1

Title: / Surname
Given names:
Address:
Telephone: / Mobile
Relationship if any to worker

Witness 2

Title: / Surname
Given names:
Address:
Telephone: / Mobile
Relationship if any to worker

Has the worker sustained any other personal injury/ies, illness/es, impairment/s or condition/s of a medical, psychiatric or psychological nature either before or after the event that may affect the degree of permanent impairment resulting from the injury to which this application relates?

Yes ð (if yes, please complete table below) No ð

Injury, illness, impairment / Date of injury / Name of treating doctor/hospital / Address of treating doctor/hospital

Has the worker ever made a claim, either before or since the event, for damages, compensation or benefits as a result of any other personal injury/ies, illness/es, impairment/s or condition/s of a medical, psychiatric or psychological nature?

Yes ð (if yes, please complete tables below) No ð

Claim number / Date of injury
Injury, illness or impairment
Name of Insurer
Address of Insurer
Name of employer against whom claim was made
Address of employer
Claim number / Date of injury
Injury, illness or impairment
Name of Insurer
Address of Insurer
Name of employer against whom claim was made
Address of employer

NB: If more claims have been made, please attach details to this form

Worker’s Statement

I declare that I wish to have the injury/ies listed on this form assessed for a degree of permanent impairment pursuant to section 132A of the Workers’ Compensation and Rehabilitation Act 2003.

I acknowledge that it is an offence under the Workers’ Compensation and Rehabilitation Act 2003 to make a statement that is false or misleading. The information I have provided is true and not misleading.

I agree to advise the insurer if my circumstances change or if I become aware of any matter that would make the above information false or misleading.

I authorise any hospital, ambulance service of the state or another state, a doctor, provider of treatment or rehabilitation services or person qualified to assess cognitive, functional or vocational capacity or an employer, or previous employer or insurers that carry on the business of providing workers’ compensation insurance, compulsory third party insurance, personal accident or illness insurance, insurance against the loss of income through disability, superannuation funds or any other type of insurance or a department, agency or instrumentality of the Commonwealth or the State or a solicitor, other than where giving information would breach legal professional privilege.

Applicant’s full name:
Applicant’s signature: / Date: / / /

If applicant is unable to sign this form:

Agent’s full name:
Agent’s signature: / Date: / / /

This form was approved by the Workers’ Compensation Regulator on 21 January 2014 pursuant to section 586 of the Workers’ Compensation and Rehabilitation Act 2003.