Form Non Work Related Injury/Illness Work Capacity Certificate

Dear Dr
Please assess Amber McCormack-Miller's fitness to return to work as an Apprentice Heavy Diesel Fitter at the OS
FFA located at Mackay.

Please note the key demands of his role:

 Travel independently to and from the facility
 Work in a workshop environment conducting high risk activities requiring a high level of executive
functioning.
 Work with heavy machinery and hand tools.
 Sustained periods of standing on a concrete base.
 Occasional walking of stairs and slopes.
 Manual lifting of objects up to 15kg.
 Long periods of welding in sustained positions.
 Undertake shift work 0600hrs – 1800hrs and 1800hrs – 0600hrs respectively.

1. WORK CAPACITY

Unfit for work from: ___________ to: ___________

Fit for full duties, no further treatment required from: _______________
Fit for full duties, but requires treatment: ___________________________________________________
Fit for some capacity for work:
o Restricted hours: ______ per day, ________days per week
o Modified/alternative duties from:_____________ to:____________ (tick relevant boxes below)
No lifting / carrying greater than ………….kgs
No or limited left / right handed work- (circle no or limited whichever is applicable)
No driving / operating heavy machinery
No driving light vehicle
No pushing / pulling
No walking on uneven ground
No climbing (ladders, scaffolding, ramps, steps)
Visual tasks only (eg: inspections)
Other (please specify) …………………….………………………………………

2. INJURY/ILLNESS MANAGEMENT PLAN

Medications:
Allied Health Treatment:
Imagery/Specialists:
Next GP Review Date:

I wish to discuss with a BHP Rehab and Return to Work Coordinator.

Please contact Rachel Sbizzirri on 0400 546 005 or rachel.sbizzirri@bhp.com
 Form Non Work Related Injury/Illness Work Capacity Certificate

Signature of Medical Practitioner: ________________________________________________________________

Name of Medical Practitioner: ___________________________________________________________________

Date: ______________________________________________________________________________________

(please use practice stamp)