/ DVA Rehabilitation Provider Approval Form
– Staff Details Sheet

Purpose

  • This form is for use by rehabilitation provider staffand should be submitted with the D9254 DVA Rehabilitation Provider Approval Form – Cover Sheet.
  • These forms enable rehabilitation provider organisations to showthat they and theirconsultants have satisfied DVA’s rehabilitation provider requirements. These requirements are in addition to Comcare requirements for approval as a workplace rehabilitation provider.
  • A Staff Details Sheet should be completed by each rehabilitation consultant within a given rehabilitation provider organisation who will provide primary case management support to a DVA client and who holds a Comcare Consultant ID.

Privacy Notice
Your personal information is protected by law, including the Privacy Act 1988. Your personal information may be collected by the Department of Veterans’ Affairs (DVA) for the delivery of government programs for war veterans, members of the Australian Defence Force, members of the Australian Federal Police and their dependants.
Read more: How DVA manages personal information
Staff Member Number on Cover Sheet
Rehabilitation Provider - Staff Member Details
  1. Name and Comcare Consultant ID:

  1. Years of rehabilitation provider experience (please specify dates):

DVA Provider Requirements
  1. Experience in working with DVA clients or other workers from a similar environment, such as police or emergency service personnel.
/ Yes No
If Yes, please provide details including:
  • The name of the organisation; and
  • A description of the services you provided.

  1. Experience in assisting clients with complex medical conditions to move to a new job with a new employer, to change careers and/or move into anew industry.
For example, an ability to produce a return to work outcome after a period of long-term unemployment. / Yes No
If Yes, please provide details.
  1. Experience in translating specific skills and qualifications to other industries. (Please detail any specific experience in translating military skills and qualifications to a civilian setting).
/ Yes No
If Yes, please provide details.
  1. Completion of e-learning courses demonstrating a knowledge of military culture and DVA services.
The mandatory e-learning courses are available onDVATrain on the DVA Website and include:
  • Non-Liability Health Care
  • Rehabilitation Online
  • Understanding the Military Experience
  • Rehabilitation Program (for consultants who register with DVA from mid-April 2017)
/ Yes No
If Yes, please provide approximate completion dates.
  1. Minimum of two years hands on experience working with clients in medical management, vocational and/or psychosocial areas. These three areas constitute DVA’s ‘whole of person’ rehabilitation approach.
Note: Wherea consultant cannot demonstrate two years’ experience, professional supervision through an employer-based mentoring program will need to be undertaken for the length of time it requires the individual to gain two years’ experience. Mentors must meet the DVA rehabilitation provider requirements and should co-sign rehabilitation reports and plans. At the end of the two year period, the mentor will need to provide DVA with a performance report certifying that the consultant meets DVA’s requirements. / Yes No
If Yes, please provide further details including:
  • Details of medical management, vocational and/or psychosocial assistance provided and the types of injury and illness profiles.

If No, please provide the below details:
  • Mentor name and Comcare consultant ID;
  • Mentor contact details; and
  • The two years’ hands on experience commencement date.

Attachments
  1. Please provide a copy of your current resume/CV (required):
/ Attached Not Attached
Declaration
Icertify that the information provided in this application is true and correct.
Staff Member Name:
Signature: / Date:

Providers should scan and email a PDF version of this Staff Details Sheet (D9255) to:

Rehab Service Providers Mailbox /

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DVA Rehabilitation Provider Approval Form – Staff Details Sheet – D9255