Forms

Partial incapacity form

Form 105 - for employers to complete

Claim form - asbestos injury

Form 202 , October 2019

Form 32 Provider management plan

A form template for the medical provider to submit an injured worker's treatment plan details to the worker's compensation insurer.

Form 71 - Request for Work Health and Safety Prosecutor (WHSP) to commence a prosecution

Request the Work Health and Safety Prosecutor to bring a prosecution under section 231 of the Work Health and Safety Act 2011 (including in relation to the Safety in Recreational Water Activities Act 2011) or section 186A of the Electrical Safety Act 2002.

Request for Specialised Program FM303

Request for Specialised Program FM303. This form is to only be used for claims where specialised programs are required at a private hospital.

Form 106 - Queensland health and safety representative (HSR) training provider application

Form 106 - Queensland health and safety representative (HSR) training provider application

Form 325B - Application for a lung disease examination

An application form for a lung disease confirmation examination under the Worker's Compensation and Rehabilitation Act 2003.

Depression, anxiety, stress, scale (dass) response form

Two page form for self-assessement

Application form – Rehabilitation and return to work coordinator (RRTWC) course approval

Version 1

Form 28 - Hazardous chemicals health monitoring report

Under the Work Health and Safety Regulation 2011 where health monitoring is required for a hazardous chemical, the PCBU must send a copy of the health monitoring report to Workplace Health and Safety Queensland in certain circumstances.

Service provider application form

Form 301: Completing this form does not guarantee referrals from WorkCover Queensland.

Form 6 - Response to lump sum offer

Response to lump sum offer pursuant to section 182B of the Workers’ Compensation Act 1990 (as amended)