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Forms

Here is a list of ReturnToWorkSA forms, sorted in alphabetical order.

For further information or advice, please contact us on 13 18 55 or email info@rtwsa.com.

If you experience any issues downloading forms, please contact us on 13 18 55.

2019-20 Retro-paid loss application form - group.docx
2019-20 Retro-paid loss (RPL) application form for group of employers

2019-20 Retro-paid loss application form - single.docx
2019-20 Retro-paid loss (RPL) application form single

Allied health capacity recommendation template
Allied health functional capacity recommendation template

Allied health mental functional capacity recommendation template
Mental health functional capacity recommendation template for Allied Health.

Authority to obtain information form (Dari)
Authority to obtain information form translated in Dari

Authority to obtain information form (Kurdish)
Authority to obtain information form translated to Kurdish.

Claim form
Call your claims agent EML 1800 688 825 or Gallagher Bassett 1800 774 177 to make a claim as this form may not be required.

Employer registration additional location form
Complete this form if you need to update your workplace location details.

Employer registration amendment form
This form allows registered employers to amend their business information and existing location information with ReturnToWorkSA. These changes can also be made via our online services portal.

Employer registration form
Use this form to register as an employer to receive insurance cover with ReturnToWorkSA. Employers must register within 14 days of employing a worker.

Exercise physiology management plan
Exercise Physiology Management Plan

Fit for work intervention outcome report template
Fit for work services intervention outcome report template.

Freedom of information (FOI) application for access form
This form should be completed for Freedom of information requests.

Graduated return to work schedule
If you are not able to return straight to your pre-injury duties following your workplace injury, you may need to return over a gradual period of time. This is when a graduated return to work schedule can be created.

Occupational therapy management plan
Occupational Therapy Management Plan

Osteopathy management plan
Osteopathy Management Plan

Physiotherapy management plan
Physiotherapy Management Plan

Physiotherapy restricted consultation application form
This application form needs to be completed if a physiotherapist is looking to undertake a restricted consultation.

Pre-injury employment durable return to work certificate template
Pre-injury employment durable return to work certificate template.

Psychology management plan
Psychology Management Plan

Recovery and return to work plan.pdf
A recovery/return to work plan is to be developed if you are likely to be away from work for more than four weeks.

Recovery return to work plan - previous version
A recovery/return to work plan is to be developed if you are likely to be away from work for more than four weeks. This is the previous version of the recovery and return to work plan.

Remuneration worksheet 2019-20
This remuneration worksheet will assist you to calculate remuneration prior to completing your 2019-20 employer remuneration return.

Remuneration worksheet 2019-20
This remuneration worksheet will assist you to calculate remuneration prior to completing your 2019-20 employer remuneration return.

Return to work coordinator appointment and change of details form
Complete this form to appoint or change the details of your Return to Work Coordinator. All businesses in South Australia who employ 30 or more workers are required to appoint and retain a trained return to work coordinator.

RISE Job vacancy information and approval form
Re-employment incentive scheme for employers (RISE) - Job vacancy information and approval form.

Section 157 application for review (Employer) form
Registered employers should complete this form if they want a review of a decision about their insurance premium.

Section 180 internal review application form
Please complete this form if you want to request a review of a decision regarding access to information under Section 180.

Self-insured - application for renewal
This document is a template that may be used when applying for renewal of registration as a self-insured employer.

Work capacity certificate
The work capacity certificate is an important tool for documenting a medical assessment of a patient's injury and their capacity to return to work.