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NSW CERTIFICATE OF CAPACITY / CERTIFICATE OF FITNESS

For use with Workers Compensation and Compulsory Third Party (CTP) motor
accident injury claims. This certificate should be completed whether the person
was employed at the time of the accident or not.
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Certificate DetailsPatient DetailsInjured Person ConsentMedical Certificate
DetailsMedical CertificationManagement PlanCapacity for WorkTreating
Practitioner Details
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Certificate Details
Claim type
CTP
Workers compensation
Is this the initial certificate for this claim?
Yes
No
Claim number
Insurer

Unknown
Patient Details

Any changes here will not be saved against the patient record. Please update the
patient record to ensure the correct details will be pre-populated next time.
First name
Last name
Date of birth

Contact number
Medicare number
Residential address (no PO box)
Suburb
State
Postcode
Occupation/Job title
Employer's name and contact details (if applicable)
Injured Person Consent
Please read this to the patient and tick if the patient has consented.
I consent to my treating medical practitioner, my employer (optional for CTP
claims), the insurer, other medical practitioners or health related
practitioners (whether consulting, treating or examining), workplace
rehabilitation providers and SIRA exchanging information for the purpose of
managing my injury and workers compensation/motor accident injury claim. I
understand this information will be used by SIRA and insurers to fulfill their
functions under the motor accident insurance and workers compensation
legislation.
Medical Certificate Details

Medical Certification
Diagnosis of work related injury/disease or motor accident related injury(ies)
Person's stated date of injury/accident

Management plan for this period
Treatment/medication type and duration
Referral to another health service or rehabilitation provider (include details
of provider type and service requested, duration and frequency when relevant)
Capacity for work
Please consider the health benefits of good work.
Do you require a copy of the position description/work duties?
Yes
No
Capacity level *
Is fit for pre-injury work
Has capacity for some type of work
Has no current capacity for any work
Factors affecting recovery
Next review date


Comments
Treating medical practitioner
Name
Provider number
Address
Suburb
State
Postcode
Contact number
I agree to be the nominated treating doctor for the ongoing management of this
person’s injury, treatment and recovery at/return to work (tick if you consent)
I certify that I am the treating medical practitioner and that I have examined
this person. The information and medical options contained in this certificate
are, to the best of my knowledge, true and correct.
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AUFRM02_2023.3313-DevR101

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