Forms
Workers compensation medical certificate
You must provide current and compliant workers compensation medical certificates to determine ongoing costs related to your injury. This medical certificate is completed by a Doctor and must include a diagnosis, recommended treatment, any restrictions to your work capacity, a date of issue and a review date (unless it is a final certificate).
Claim for time off work (CFTOW)
For any periods of work incapacity please submit a CFTOW form available below.
All employees with an open workers compensation claim, who are medically certified as unable to work will be required to submit a personal leave request (SLWC – Sick leave with certificate) via HORUS. Once the employee has submitted a claim for time off work, the University will accept or deny liability for the period of time. If the claim for time off work is accepted, the SLWC application will then be updated to Workers' Compensation Leave (WCL) by Remuneration & Conditions Branch, ANU, and the sick leave will be re-credited.
Documents
Lodging a claim
- Workers' Compensation Claim Form (PDF, 614.36 KB)
- ANU Workers' Compensation Claim Pack (PDF, 993.54 KB)
- Medical certificate of capacity for work (PDF, 210.01 KB)
- Claim for time of work (PDF, 162.41 KB)
- Medical Services Claim form (PDF, 295.74 KB)
- Authority to Collect, Use and Disclose Personal Information (PDF, 245.9 KB)
- Journey claim form (PDF, 195.18 KB)
Use contact details to request an alternative file format.
Claim forms (beneifts)
- Physiotherapy Treatment Notification Plan (PDF, 503.25 KB)
- Psychological Treatment Notification Plan (PDF, 714.9 KB)
- Psychology counselling extended consultation request (PDF, 110.04 KB)
- Claim for Exercise as Medical Treatment (PDF, 283.56 KB)
- Claim for Aids or Appliances Excluding Hearing Aids (PDF, 168.14 KB)
- Claim for alterations to a place of residence and or work (PDF, 245.92 KB)
- Record of earnings - claim for incapacity for work (PDF, 169.6 KB)
Use contact details to request an alternative file format.
Requesting reconsideration - claims delegate decision
- Reconsideration Request Form (PDF, 208.83 KB)
- Your rights regarding a determination (PDF, 643.88 KB)
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Personal details forms
- Request to change bank acount and or personal details (PDF, 250.43 KB)
- Periodic review form (PDF, 809.26 KB)
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Rehabilitation forms
- Rehabilitation program (PDF, 457.59 KB)
- Rehabilitation assessment & examination (PDF, 381.05 KB)
- Rehabilitation program closure record (PDF, 375.75 KB)
- Work trial agreement (PDF, 827.21 KB)
- Rehabilitation program alteration (PDF, 414.48 KB)
- Suitable Duties Plan (PDF, 190.57 KB)
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Separation
- Cessation of Employment (PDF, 196.61 KB)
- Authority and consent for the release of superannuation information (PDF, 143.81 KB)
Use contact details to request an alternative file format.
Page Owner: Human Resources