Early Medical Assessment

Fruit and Vegetable Retailing

Administration Officer

Fruit and Vegetable Retailing

Administration Officer

Dear Doctor: This form will take up to 5 minutes to complete. Please review each task the worker undertakes (both picture and written description) and tick whether or not the worker can complete this task. If modification required, please leave comments. Space at the end of this document is available for final comments and recommendations.

Administration Mainly computer based; therefore constant sitting involved. Phone calls taken as required Data entry of invoices Filing of invoices in compactus involving pushing system open and accessing shelves Office is located upstairs therefore stair climbing involved.	Doctor Approval Yes No Comments:

Work Capacity Form

Doctor Review (include final comments)

I confirm that in my view, subject to the above comments, the worker is able to perform certain duties detailed in this Early Medical Assessment.

These duties should be reassessed on:	Date:

Signature :	Date:

Employers Declaration:

I confirm that I/we have reviewed the Doctor’s recommendations and comments. I/we will make suitable changes to make allowances for the Doctor’s recommendations.

Signature :	Date:

Employees Declaration

My Doctor has discussed their recommendations with me. I have been given the opportunity to participate in this process.

Signature :	Date:

For information on completing this form, please contact Business SA on 08 8300 0000.

Disclaimer: This document is published by Business SA with funding from ReturnToWorkSA. All workplaces and circumstances are different and this document should be used as a guide only. It is not diagnostic and should not replace consultation, evaluation, or personal services including examination and an agreed course of action by a licensed practitioner. Business SA and ReturnToWorkSA and their affiliates and their respective agents do not accept any liability for injury, loss or damage arising from the use or reliance on this document. The copyright owner provides permission to reproduce and adapt this document for the purposes indicated and to tailor it (as intended) for individual circumstances. (C) 2016 ReturnToWorkSA