Upload File

fact sheet web view☐ insurer’s injury management plan covers the duration of the work ......

  • Home
  • Documents
  • Fact Sheet Web view☐ Insurer’s injury management plan covers the duration of the work ... Conflict of interest ... ☐Trainee capabilities noted (eg self-reported tolerances, skills)
3
Work trial checklist This checklist is designed to help workplace rehabilitation providers ensure all necessary work trial considerations have been made with reference to the SIRA Work trial guidance material. Return to work goal ☐ Goal identified, relevant parties reach agreement ☐ Work trial position supports agreed return to work goal ☐ Insurer’s injury management plan covers the duration of the work trial Eligibility for work trial ☐ At time of program commencement worker/trainee is receiving or entitled to receive weekly payments ☐ Work trial host eligibility and suitability confirmed ☐ No other trainees undertaking work trial with host Conflict of interest ☐ No conflict of interest identified OR ☐ Potential conflict of interest identified and strategies to address issues outlined Workplace assessment ☐ Trainee and host present during assessment ☐ Trainee capabilities noted (eg self-reported tolerances, skills) ☐ Work tasks and demands outlined (physical, psychosocial, cognitive, environmental) ☐ Trainee’s capacity matched to work requirements

Upload: hadan

Post on 08-Mar-2018

216 views

Category:

Documents


3 download

Report

TRANSCRIPT

Page 1: Fact Sheet Web view☐ Insurer’s injury management plan covers the duration of the work ... Conflict of interest ... ☐Trainee capabilities noted (eg self-reported tolerances, skills)

Work trial checklist

This checklist is designed to help workplace rehabilitation providers ensure all necessary work trial considerations have been made with reference to the SIRA Work trial guidance material.

Return to work goal☐ Goal identified, relevant parties reach agreement ☐ Work trial position supports agreed return to work goal ☐ Insurer’s injury management plan covers the duration of the work trial

Eligibility for work trial ☐ At time of program commencement worker/trainee is receiving or entitled to receive

weekly payments☐ Work trial host eligibility and suitability confirmed ☐ No other trainees undertaking work trial with host

Conflict of interest ☐ No conflict of interest identified OR☐ Potential conflict of interest identified and strategies to address issues outlined

Workplace assessment ☐ Trainee and host present during assessment ☐ Trainee capabilities noted (eg self-reported tolerances, skills) ☐ Work tasks and demands outlined (physical, psychosocial, cognitive, environmental) ☐ Trainee’s capacity matched to work requirements ☐ Work health and safety issues considered and addressed ☐ Host supervisory arrangements confirmed ☐ Confirmation with host that trainee will be supernumerary ☐ Comment regarding safety and suitability of proposed work trial☐ Need for equipment and/or training considered and addressed

Page 2: Fact Sheet Web view☐ Insurer’s injury management plan covers the duration of the work ... Conflict of interest ... ☐Trainee capabilities noted (eg self-reported tolerances, skills)

Recover at work plan☐ Work goal, work trial position and work duties included☐ Date of commencement and completion stated☐ Work attendance arrangements (hours or days of work)☐ Work capacity outlined☐ Monitoring arrangements and review date(s) added☐ Details of equipment, workplace modifications ☐ Strategies to address any identified concerns ☐ Evidence of agreement of trainee and host

Work trial agreement☐ Agreement has been explained, signed and a copy provided to trainee and host

Insurances ☐ Relevant insurances confirmed with trainee and host

Notification of injury ☐ Trainee and host informed of injury notification requirements

All evidence relating to the work trial must be retained on file. This information may be reviewed by SIRA as a part of provider evaluations.

SignatureRehabilitation consultant:

Date (DD/MM/YYYY):


07 Medical Assessment Adult - fimmccall.com · 3 MEDICAL HISTORY (cont…) ☐ ☐ Skin Cancer ☐ ☐ Other þ = Past Condition þ = Ongoing Condition ☐ ☐ Autism ☐ ☐ Mild

The complete RSPB pin badge range...☐ badger 1 ☐ badger 2 ☐ bald Ibis ☐ banded snail ☐ barn owl 1 ☐ barn owl 2 ☐ barnacle goose 1 ☐ barnacle goose 2 ☐ basking shark

Lenze 8400 BaseLine Inverter Drives - ValinOnline.com · GOST-R Degreeofprotection EN605292) IP20 NEMA250 Type1 ... Inverter E84AV☐☐☐1124☐☐0 E84AV☐☐☐1524☐☐0 E84AV☐☐☐2224☐☐0

Automationsystems Drivesolutions Motorslenze.ir/wp-content/uploads/2018/08/CAT_MT_MDHF_15593806... · 2018. 8. 5. · 2.20 mf☐☐☐☐☐080-32 e84dvb☐2224s☐☐☐2☐ e84av☐☐☐2224☐☐0

Health History Questionnaire: General Nutrition ......☐ Anxiety Disorder ☐ Diabetes – Non‐Insulin ☐ HIV or AIDS ☐ Polycystic Ovarian ... ☐ Blood Clots (or DVT) ☐ Eating

TABLE OF CONTENTS Contract.pdf · ☐ Low Season ☐ Studio, 2 Sleeper ☐ Economy ☐ Weekend / Midweek ☐ Mid-Season ☐ 1 Bedroom, 4 Sleeper ☐ Standard ☐ 1 Week ☐ High-Season

INSURER’S ANNUAL REPORT - PA.Gov

Registration Checklist 1 Grade · ☐Korean (203) ☐Filipino (400) ☐Samoan (303) ☐Vietnamese (204) ☐Hmong (208) ☐Tahitian (304) ☐Asian Indian (205) ☐Other Asian (299)

CUSC-CCREU · eval3 concern shown by the university for you as an individual ☐ ☐ ☐ ☐ eval9 your decision to attend this university ☐ ☐ ☐ ☐ eval12 Would you recommend

Blog Post Ideas · Blog Post Ideas danischnakenberg.com0000000000©Simplify0Mommyhood ... ☐Twitter ☐Google+ Linked Up: ☐M ☐T ☐W ☐T ☐F ☐Sa/Su Post Title: Post Title:

Lenze MF Three-Phase AC Motors Catalogmf☐☐☐☐☐080-42 3.00 3480 210 11.4 370 6.60 mf☐☐☐☐☐090-32 4.00 3480 370 8.50 mf☐☐☐☐☐100-12 5.50 3525 340 12.9 mf☐☐☐☐☐100-32

Formica Interior Panel Laminates: Wood Species · Wood Species: Wood Stains**: ☐ Country Pine ☐ Golden Oak ☐ Traditional Cherry ☐ Mahogany ☐ Maple ☐ Red Oak ☐ Walnut

BULLETIN D’INSCRIPTION...BULLETIN D’INSCRIPTION FORMATIONS ... ☐ 25 Juin Paris 2016 ☐ 16 Janvier ☐ 13 Février ☐ 12 Mars ☐ 16 Avril ☐ 14 Mai ☐ 18 Juin ☐ 9 Juillet

Strengthen Your Faith This Easter · ☐ day 1 ☐ day 2 ☐ day 3 ☐ day 4 ☐ day 5 ☐ day 6 ☐ day 7 ☐ day 8 ☐ day 9 ☐ day 10 ☐ day 11 ☐ day 12 ☐ day 13 ☐ day

unfccc.int  · Web view☐ Desertification ☐ Glacier retreat and related impacts ☐ Increasing temperatures ☐ Land and forest degradation ☐ Loss of biodiversity ☐ Ocean

COMMUNITY DEVELOPMENT DEPARTMENT Application For …...☐ New Installation ☐ Minor Alteration ☐ Major Alteration ☐ Repair ☐ Tank replacement Authorization ☐ with field visit;

Table of Contents - lmci.state.tx.us Web view☐☐☐ welding ☐☐☐ fitting eyeglasses ☐☐☐ processing X-rays ... She began taking computer and word processing classes at

Participant Accident Death, Dismemberment, Injury and/or ... · Participant. Accident Death, Dismemberment, Injury and/or Sickness Claim Form ( ) ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐

ADMINISTRATIVE · 851 30th Avenue SE | Rochester MN 55904 | 507-280-3157 Registration Form Registration Deadline is 4/1/2020 ☐ ☐ ☐ ☐ ☐ ☐

floridaavenueelementary.stpsb.orgfloridaavenueelementary.stpsb.org/.../FAE17_18SIP.docx  · Web view☐Title IV ☐Perkins ☐JAG ☐Bond Money ... ☐ I certify that this school

EMPLOYMENT APPLICATION Teaching Position...SUBJECT AREAS ☐ French (Basic) ☐ Music (Band) ☐ Aboriginal Studies ☐ French (FSL) ☐ Music (Choral) ☐ ☐Arts French (Immersion)

Program Observation Tool NAEYC Site Visit · ☐ loose parts1 ☐ ride-on toys ☐ ride-on pathway ☐ slide ☐ garden ☐ gross motor game equipment 2 ☐ open spaces ☐ dramatic

GROCERY LIST - Bodybuilding.com...GROCERY LIST PROTEIN ☐ Chicken Breast ☐ Turkey Breast ☐ Cod ☐ Tilapia ☐ Pollok ☐ Low-fat steak (one meal per day) ☐ Salmon (one meal

Name: CERT Level · ☐First Aid ☐CPR / AED ☐Wilderness 1st Aid ☐EMR ☐EMT ☐Disaster Services ☐Shelter Fundamentals ☐Psychological 1st Aid ☐Pet 1st Aid ☐Food Handling

Kitchen Spec Sheet - shademtngranite.comshademtngranite.com/.../2020/10/Kitchen_Spec_Sheet.pdf · ☐Granite ☐Quartz ☐Solid Surface ☐Laminate ☐Other Brand_____ Color _____

Export Marketing Assistance Service (EMAS) Application ... · 3 of 4 West Africa: East Africa: ☐Nigeria ☐Cote d'Ivoire ☐Liberia ☐Kenya ☐Uganda ☐Rwanda ☐Tanzania 2 4.We

MAGLEV TRAIN - discovere.org Guide_Grade 3_030518... · ☐ Paper Per group: ☐ Paper ☐ Pens or pencils ☐ Cardstock paper ☐ Scissors ☐ 6 inches of magnetic tape ☐ 4 disc

acsva.orgacsva.org/.../uploads/2019/08/Buddy-System-New-Membe…  · Web view☐ Chemistry Olympiad☐Chemistry Week☐Chemistry Education☐Membership ☐ Media Relations☐Project

ceremony 2…  · Web view☐Romania ☐Russia☐Samoa ☐Scotland ☐South Africa ☐Spain☐Tonga☐Uruguay ☐USA☐Wales

2019/20 Membership Application Form · ☐Catering ☐Event Management Companies ☐Event Support Services ☐Venues ☐Inbound Tour Operators ☐Tour Desks ☐Travel Agents ☐Wholesale

UNITEDHEALTHCARE INSURANCE COMPANY ESL STUDENTS … · ☐ 2157-6 Guatemalan ☐ 2157-6 Guatemalan ☐ 2071-9 Haitian ☐ 2071-9 Haitian ☐ 2158-4 Honduran ☐ 2158-4 Honduran ☐

Service Delivery Areas DFPS Texas and Regional Maps · ☐ Dallas ☐ Navarro*** ☐ Denton ☐ Palo Pinto*** ☐ Ellis*** ☐ Parker*** ☐ Erath*** ☐ Rockwall*** ☐ Fannin***

The complete RSPB pin badge range€¦ · ☐ orca ☐ osprey 1 ☐ osprey 2 ☐ osprey 3 (silver) ☐ osprey 5 ☐ otter 1 ☐ oystercatcher 1 ☐ oystercatcher 2 ☐ peacock butterfly

HEAD SHOT HERE - hemophilia.ca · Poison Ivy ☐ Insect Bites ☐ Peanuts ☐ Penicillin ☐ Animals ☐ Food ☐ Drugs ☐ Other ☐ _ _ _ _ 3. Epipen or Anakit Does he/she have

Sight Words Second Grade - funwithmama.com · Second Grade Sight Words Checklist ☐always ☐around ☐because ☐been ☐before ☐best ☐both ☐buy ☐call ☐cold ☐does ☐don’t