Safety, Rehabilitation and Compensation Act 1988

Sections 34K and 34S

COMCARE APPLICATION FOR

RENEWAL OF APPROVAL

AS A REHABILITATION PROGRAM PROVIDER (WORKPLACE REHABILITATION PROVIDER)

This application form has been approved under section 34S of the Safety, Rehabilitation and Compensation Act 1988 for the purposes of section 34K of that Act. It is to be completed by approved rehabilitation providers seeking renewal of approval under that Act.

Section 1

INFORMATION ON APPLYING FOR COMCARE RENEWAL

Workplace rehabilitation providers who are currently approved by Comcare as rehabilitation program providers under section 34 of the Safety, Rehabilitation and Compensation Act 1988 (SRC Act) may apply to Comcare for renewal of approval for the approval period from 1 July 2010 to 30 June 2013.
The application must be in writing on this approved form, accompanied by the prescribed fee, and submitted to Comcare by 31 December 2009.
Comcare has incorporated key elements of the heads of Workers’ Compensation Authorities (HWCA) endorsed nationally consistent approval process, namely the national Conditions of Approval and the Principles of workplace rehabilitation into the Criteria for initial approval or renewal of approval as a rehabilitation program provider (workplace rehabilitation provider), and the Operational Standards for rehabilitation program providers (workplace rehabilitation providers). This is in preparation for the renewal process and the commencement of the national approval framework from 1 July 2010.
This prescribed renewal application form is comprised of the HWCA endorsed ‘national renewal application form’ and also contains Comcare specific renewal requirements pursuant to section 34L of the Safety, Rehabilitation and Compensation Act 1988 (the SRC Act).
Comcare will make a decision to renew the approval of renewal applicants, according to section 34L of the SRC Act, where it is satisfied that the provider:
1. meets the section 34 criteria
2. has demonstrated compliance with the operational standards in force since the applicant was initially approved or last renewed, and
3. is likely to meet the section 34E operational standards to be in force from the renewal date.

The renewal process

6. There are a number of stages in the renewal process:

The applicant completes the renewal application form (Section 2) and submits all required information and documentation relevant to renewal in this scheme
Comcare assesses the application and the provider’s performance against Comcare’s operational standards for the current period
Where a provider is applying for approval or renewal to another workers’ compensation authority (or is currently approved by another authority) Comcare may liaise with that authority to discuss or confirm conformance against the national Conditions of Approval and the Principles of workplace rehabilitation
Comcare issues a written decision renewing, renewing with conditions or refusing to renew the provider’s approval for the approval period from 1 July 2010 to 30 June 2013.

The provider application

7. This prescribed Comcare application form contains:

Section 1 Information on applying for Comcare renewal.

Section 2 HWCA endorsed Renewal application form for approval as a workplace rehabilitation provider, including Appendix 4 & 5 applicable to Comcare renewal only.

Section 2 includes:

Information to complete the HWCA ‘national’ renewal form and renewal application requirements including:

Part A Applicant details (Please ensure this is relevant to your Comcare application with Comcare approval numbers etc)

Part B Conforming to the national Conditions of Approval including the Principles of Workplace Rehabilitation)

Appendix 1 Staff details- (Please include Comcare scheme approved staff only)

Appendix 2 Statement of Commitment to the Conditions of Approval (for completion and signing)

Appendix 3 Statement of Commitment to the Code of Conduct for Workplace Rehabilitation Providers (for completion and signing)

 Comcare additional requirements

Appendix 4 Comcare Renewal Requirements - this examines whether the provider has met Comcare’s approval criteria for the current approval period (since 1 July 2001).

Appendix 5 Comcare Agreement & Authorisation (for completion and signing).

8. Throughout this process Comcare may consult with the provider and may at any time request further information in writing from the provider.

Lodgement of application form

9. The provider should lodge the application or otherwise advise Comcare that they do not wish to seek renewal by 31 December 2009.

10. Comcare will accept applications where the applicant can provide proof of lodgement by post prior to 31 December 2009. Comcare will acknowledge receipt of the application in writing.

11. The application should be accompanied by the prescribed Comcare renewal application fee.

12. Late applications may only be considered in exceptional circumstances [see section 34J (3) of the SRC Act].

13. Please submit the completed application by 31 December 2009 to:

The Director

SRC Policy Section

GPO Box 9905

Canberra City ACT 2601

Email: rehab.approval@comcare.gov.au

Phone enquires: 1300 366 979

Integrity of the renewal process

14. To ensure the integrity of the renewal process, Comcare may conduct audits of randomly selected applicants for renewal or may seek to consult with the other Workers’ Compensation Authorities in which the applicant is seeking approval/renewal.

Outcome standards assessment

15. Benchmarked outcome standards under s34E of the SRC Act have been determined by Comcare and measure a provider’s effectiveness, availability and cost (and other such standards Comcare considers appropriate). The outcome standards are published on Comcare’s website www.comcare.gov.au and available in the publication ‘operational standards for rehabilitation program providers (workplace rehabilitation providers)’.

16. Comcare will examine each provider’s performance against the outcome standards in respect of the current period of approval. The provider’s performance is based on all closed return to work plans for the relevant period. The results will be assessed for compliance against each standard’s performance measure.

17. For rehabilitation program work undertaken for Comcare scheme employers other than a Commonwealth Premium paying agency, the provider is required to provide summary of their achievement against the outcome standards and where necessary, provide an explanatory statement as to why a standard had not been met.

Service standards assessment

18. Comcare will examine the provider’s record of meeting the current service delivery standards and will examine the provider’s description of its return to work processes to form a view on whether it will be likely to meet the operational standards in force for the three year approval period from 1 July 2010.

Where a provider has failed to meet a standard

19. If a provider identifies poor performance against a standard the provider must attach an explanatory statement at the time of submitting the application. Comcare considers performance by a provider against each individual standard within the context of overall performance against all standards.

20. Factors which may be considered include servicing remote areas, managing complex injuries, assisting with redeployment and late intervention cases.

Renewal of approval decision

21. If Comcare is satisfied, having regard to the information in the application, or any additional information supplied, that the provider meets the application criteria and has demonstrated compliance with the operational standards in force since the provider was initially approved or last renewed and is likely to meet the operational standards from the renewal period, it will renew the approval of the provider for a period of three years and inform the provider of its decision in writing.

22. Comcare may also grant a conditional renewal of approval. The provider would be advised of the conditions and their review rights in writing.

23. If Comcare refuses to renew the applicant’s approval, the provider will be advised of the reasons and their review rights in writing.

In this application form:

‘applicant’ includes:

(a) a sole trader;

(b) a partnership; and

‘Approval Criteria’ means the criteria for the initial approval or renewal of approval as a rehabilitation program provider (workplace rehabilitation provider) from time to time in force under section 34D of the SRC Act.

‘Code of Conduct’ means the HWCA endorsed Code of Conduct for Workplace Rehabilitation Providers as at 23 October 2009.

‘employer’ means the Entity, Commonwealth authority or licensed corporation employing the employee.

Note: The expressions Entity, Commonwealth Authority and licensed corporation are defined by subsection 4(1) of the SRC Act.

‘Guide’ means the HWCA document “Guide: Nationally Consistent Approval Framework for Workplace Rehabilitation Providers” published on the HWCA website www.hwca.org.au .

‘HWCA’ means the Heads of Workers’ Compensation Authorities.

‘national Conditions of approval’ means the HWCA endorsed national conditions of approval as at 23 October 2009.

‘principal’ has the same meaning as that term is defined in section 34 of the SRC Act, namely:

(a) if the applicant is a partnership—any of the partners, and

(b) if the applicant is a company—any of the directors of the company and, if the person responsible for the day to day running of the company is not a director, also that person.

‘provider’ means a person (including a partnership or company) that is approved as a rehabilitation program provider (workplace rehabilitation provider) under the SRC Act, and includes any principal of the provider.

‘Principles of Workplace rehabilitation’ means the HWCA endorsed Principles of Workplace Rehabilitation as at 23 October 2009.

‘rehabilitation program provider’ and ‘workplace rehabilitation provider’ have the same meaning.

‘the SRC Act’ means the Safety, Rehabilitation and Compensation Act 1988.

Notes:

Authentic copies of the Code of Conduct, the national Conditions of approval and the Principles of Workplace rehabilitation as at 23 October 2009 are published on the Comcare website at www.comcare.gov.au .
Authentic copies of the approval criteria and the operational standards are available on the Federal Register of Legislative Instruments as www.comlaw.gov.au and on the Comcare website at www.comcare.gov.au . The approval criteria and the operational standards are disallowable legislative instruments within the meaning of the Legislative Instruments Act 2003.

Section 2

HWCA endorsed:

Renewal Application for

Approval as a Workplace Rehabilitation Provider

This application will be completed by organisations wishing to apply for a renewal of an Instrument of Approval as a workplace rehabilitation provider.

This application should be read in conjunction with the document “Guide: Nationally Consistent Approval Framework for Workplace Rehabilitation Providers” available on the Heads of Workers’ Compensation Authorities website www.hwca.org.au

Contents

Introduction

Information to Complete the Renewal Application

Renewal Application Requirements

Part A – Applicant Details

Part B – Conforming to the Conditions of Approval

Appendix 1 - Staff Details

Appendix 2 - Statement of Commitment to the Conditions of Approval

Appendix 3 - Statement of Commitment to the Code of Conduct for Workplace Rehabilitation Providers

Appendix 4- Comcare renewal requirements.....................................24

Appendix 5- Comcare Agreement & Authorisation................................26

Introduction

The Heads of Workers’ Compensation Authorities (HWCA) endorsed a nationally consistent framework for the approval of workplace rehabilitation providers in June 2008. The details of the approval framework are contained in the HWCA document “Guide: Nationally Consistent Approval Framework for Workplace Rehabilitation Providers”.

Providers should ensure they remain fully conversant with the framework contained in the Guide prior to making a renewal application.

If the renewal application is successful, a further Instrument of Approval as a workplace rehabilitation provider will be issued for a 3-year period, until 30th June of the third year.

Information to Complete the Renewal Application

A completed renewal application must be submitted using this renewal application template to the workers’ compensation authority in the jurisdiction in which approval is sought and be accompanied by the prescribed fee, where appropriate.
Applicants should refer to the appropriate website of the workers’ compensation authority to confirm email and/or address details where the application must be lodged and what application fee may apply.
Applicants should ensure their renewal application contains sufficient information and is accompanied by the necessary supporting documentation to demonstrate their capacity to meet the Conditions of Approval (see the Guide, section 6 – Conditions of Approval).
The workers’ compensation authority will approve a renewal application where it is satisfied that the applicant conforms to the Conditions of Approval. The workers’ compensation authority will inform the applicant of its decision to approve their renewal application by issuing a further Instrument of Approval for a 3-year period.
A further Instrument of Approval is issued for a maximum period of 3 years, until 30 June of the third year. In order to continue to provide services beyond this date a workplace rehabilitation provider will be required to make a renewal application within the third year as prescribed by the workers’ compensation authority where renewal of approval is sought.
During the 3-year approval period, the workplace rehabilitation provider will participate in annual self-evaluations and any independent evaluation as required by the workers’ compensation authority to determine conformance with the Conditions of Approval.
Should a renewal application not conform to all the Conditions of Approval, the organisation will be given an opportunity to provide further information. Subsequent to this, if the organisation still does not conform to all the Conditions of Approval then the renewal application is considered to be unsuccessful. In this instance, 50% of the renewal application fee may be refunded.
If an application for renewal is unsuccessful, the applicant will be advised of the reasons and the appeals process relevant to the workers’ compensation authority.
An applicant that has been unsuccessful in their renewal application will not be eligible to apply for a renewal of approval until they can demonstrate to the workers’ compensation authority’s satisfaction that the reasons for non approval no longer exist.
The provision of false or misleading information is a serious offence and will nullify the Instrument of Approval.

Renewal Application Requirements

The renewal application includes the following requirements that must be completed to demonstrate how a provider will conform to the Conditions of Approval.

Provider details including:
1. Business ownership details including association or connection with other organisations supplying services within the workers’ compensation industry.
2. Documentation demonstrating how the applicant meets the Conditions of Approval.
A signed Statement of Commitment to the Conditions of Approval (Section 2.4, page 22).
A signed Statement of Commitment to the Code of Conduct for Workplace Rehabilitation Providers (Appendix 2.5, page 24).
Current staff details completed for each location where workplace rehabilitation services may be delivered in the event that the renewal application is approved (one sheet per location).
The prescribed fee, where appropriate.
Any other documentation requested by the workers’ compensation authority as part of considering the renewal application.

While considering a renewal application, the workers’ compensation authority may at any time request further information in writing from the provider and may liaise with other workers’ compensation authorities where the provider delivers workplace rehabilitation services to exchange information about the application.

Part A – Applicant Details

Name of the workers’ compensation authority where this application is being submitted to:

______________________________________________________________________

Business Name
2. ABN and origin (to determine location of ‘home’ jurisdiction)	Attach copy of the ABN record from the Australian Business Registry.
3. Organisation	Indicate the nature of your organisation (i.e. company, partnership, sole trader, individual subsidiary of a Government body) Full name of your organisation including trading name ACN Name and address of any parent organisation, if applicable. Name and position of person/s authorised to sign this application on behalf of the organisation.
4. Provider/site approval numbers	List the number(s) issued by the workers’ compensation authority.
5. Addresses	Organisation Address Postal Address
6. Phone Number
7. Fax
8. Email
9. Contact person for this application	Name Title Phone Email

10. Name of person/s who meet the organisational management structure requirements as outlined in Section 2.2, Principle Two: Organisational & administrative arrangements in particular sub-principle 2.5 of this form.	Name/s Titles Qualifications and workplace rehabilitation experience of the person/s meeting this requirement Phone Email
11. Other workers compensation authorities where approval has been granted.	List the jurisdictions in which the applicant has a current Instrument of Approval.
12. Referees	Provide the contact details of two referees who can attest to your organisation’s suitability as a workplace rehabilitation provider organisation including statements as to the professional integrity, honesty and due diligence of your organisation’s owner/s and/or management.

13. Previous Applications	Has your organisation, any of its owner/s and/or management and/or any persons employed or engaged to deliver workplace rehabilitation services by your organisation been refused approval as a provider of rehabilitation services or had approval been withdrawn as a provider of rehabilitation services in any Australian workers’ compensation jurisdictions? Yes / No If so, provide details of the circumstances and reasons why there is no cause to reject your organisation’s application. These details should state whether the refused approval was associated with: Your organisation, or Any of its owner/s, or Any of its management, or Any of its employees including contractors and staff.

14. Conflict of Interest

Detail all your organisation’s business affiliations with other suppliers of services within any of the workers’ compensation authorities and how you will manage any actual or perceived conflict of interest.

15. Professional misconduct or criminal proceedings

Outline if any proceedings have been taken (or are pending) against any of the following, in relation to professional misconduct or criminal proceedings, breaches of the privacy act or financial administration acts. If so, provide details of the circumstances and reasons why there is no cause to reject your organisation’s application. These details should state whether the circumstances and reasons was associated with:

Your organisation, or
Any of its owner/s, or
Any of its management, or
Any of its employees including contractors and staff.

16. Insurance Documents as outlined in Section 2.2, Principle Two: Organisational & administrative arrangements in particular sub-principle 2.1 of this form.

In the context of workplace rehabilitation service provision, please attach copies of your organisation’s:

Professional Indemnity Certificate of Currency
Public Liability Certificate of Currency
Workers Compensation Certificate of Currency

Part B – Conforming to the Conditions of Approval

A renewal application must demonstrate how the provider will conform to the Conditions of Approval.

1. Principles of Workplace Rehabilitation

Principle One: Service provision

1.1 A focus on return to work

Expectations that a return to work goal and the services required are established with relevant parties at the commencement and throughout service provision (relevant parties include worker, employer, insurer, other service providers).
Appropriate services are identified and delivered to maximise return to work.
Services focus initially on return to work in the worker’s pre-injury employment or, if that is not possible, with another employer.

Provide a succinct statement on what this means to your organisation and how you will apply this principle and its indicators. For example consider what would you say to an injured worker or an employer about what this means and what will occur.

1.2 The right services provided at the right time

Workers receive prompt attention and intervention appropriate to their needs.
Barriers, risks and strengths are identified and strategies promptly implemented.
Services are actively coordinated and integrated with other injury management and return to work activities.

1.3 Effective service provision at an appropriate cost

Needs of the worker and employer are identified by means of adequate and appropriate assessment.
Service levels match the worker and employer needs.
Service costs match the range and extent of service provision.

1.4 Effective communication with all the relevant parties

Respectful, open and effective working relationships established and maintained with and between workers and employers and other relevant parties.

b. The provider acts as the link between treatment providers and the workplace to translate functional gains into meaningful work activity.

c. Progress towards the return to work goal is communicated to interested parties throughout service provision.

d. Durability of employment is confirmed 13 weeks after placement.

1.5 Evidence based decisions

a. Assessments demonstrate need for service.

b. The type of service selected is the most appropriate and cost effective of those available to achieve the return to work goal.

c. An equitable and consistently applied approach to recommending commencement and cessation of service delivery.

d. Consideration given to workplace industrial relations and human resource matters that may affect the worker’s return to work.

Principle Two: Organisational and Administrative arrangements

2.1 Comprehensive and robust corporate governance infrastructure

Systems of probity that avoid conflict of interest as well as prevent, manage and report malpractice/fraud.
Appropriate financial administration including accurate accounting.
Maintenance of appropriate and adequate insurances, including professional indemnity, public liability and workers’ compensation.
Data collection, analysis and reporting of provider performance including return to work and durable return to work rates.

Provide a succinct statement on what this means to your organisation and how you will apply this principle and its indicators.

2.2 A records management system meeting State and Commonwealth legislation requirements

Comprehensive, accurate and accessible records pertaining to all clients, staff and business operations.
Security of storage of records in accordance with legislative requirements.

Provide a succinct statement on how you will apply this principle and its indicators.

2.3 Privacy and confidentiality practices meeting relevant privacy legislation requirements

Systems that incorporate privacy and confidentiality requirements within all aspects of the organisational and administrative arrangements.

Provide a succinct statement on what this means to your organisation and how you will apply this principle and its indicators.

2.4 Safe work practices as well as return to work and injury management policies

b. Systems that comply with relevant injury management and workers compensation legislation.

c. Systems that comply with local workplace health and safety legislation.

Provide a succinct statement on what this means to your organisation and how you will apply this principle and its indicators.

2.5 Organisational management structure requirements

At least one person in the management structure with a qualification recognised as being sufficient to satisfy the requirements of a Workplace Rehabilitation Consultant and who is able to demonstrate at least five year’s relevant workplace rehabilitation experience (also refer to 4.1.a. Minimum Workplace Rehabilitation Consultant qualifications).

Provide a certified copy of the qualifications and experience of the personnel who meet and will continue to meet this condition.

Principle Three: Quality Assurance and Continuous Improvement

3.1 Quality Model

Quality systems that ensure customer focused service delivery, and collect, analyse and monitor qualitative and quantitative data to identify areas of strength and opportunities for systems and service improvement.

Provide a succinct statement on what this means to your organisation and how you will apply this principle and its indicators.

3.2 Quality Assurance

Implementation of appropriate review mechanisms (e.g. annual self evaluations and internal peer reviews) to assure conformance with the Conditions of Approval.
Implementation and documentation of corrective and preventative actions and monitoring and review of their effectiveness.

Provide a succinct statement on what this means to your organisation and how you will apply this principle and its indicators.

3.3 Customer focus

System to collect, review, analyse and action solicited and unsolicited feedback from customers.
Implementation of an effective complaints management system.

Provide a succinct statement on what this means to your organisation and how you will apply this principle and its indicators.

3.4 Continuous improvement.

Systems for analysing information and data to identify opportunities for improvement.
Planning, piloting, refining and implementing improvement strategies.
Monitoring and review the effectiveness of any improvement strategies.

Provide a succinct statement on what this means to your organisation and how you will apply this principle and its indicators.

Principle Four: Staff Management

4.1 Qualifications, knowledge and experience

Systems for ensuring that Workplace Rehabilitation Consultants have the minimum qualifications (as outlined below) and the qualifications are verified.

Workplace Rehabilitation Consultants will have a qualification recognised, accredited or registered by one of the following associations or state registration boards:

Australian Society of Rehabilitation Counsellors
Rehabilitation Counselling Association of Australia
Australian Association of Occupational Therapists (registered in QLD, SA, NT and WA)
Physiotherapist Registration Board (registered)
Australian Association of Exercise and Sports Science (accredited as Exercise Physiologists)
Psychologists Registration Board (registered)
Speech Pathology Australia
Australian Association of Social Workers
Medical Board (registered)
Nurses Registration Board (registered)

AND 12 months or more experience delivering workplace rehabilitation services.

Where Workplace Rehabilitation Consultants have less than 12 months’ experience delivering workplace rehabilitation services, a comprehensive induction program will be completed and professional supervision provided for at least 12 months.

Note: Some workplace rehabilitation services can only be delivered by designated professional groups. The minimum qualifications to deliver these services are included in the description of the workplace rehabilitation services as specified by each jurisdiction.

b. Workplace Rehabilitation Consultants have the appropriate skills, knowledge, and experience to deliver workplace rehabilitation services.

c. Workplace Rehabilitation Consultants have knowledge of injury management principles and workers compensation legislation, policy and procedure.

d. All staff interacting with injured workers and workplaces have undergone current checks and clearances where appropriate (e.g. police, security, OHS and child protection).

Your organisation must provide a completed Staff Details sheet - for each location being proposed as part of this application (see Appendix 1 - Staff Details, page 20)

Provide a succinct statement on what this means to your organisation and how you will apply this principle with particular reference made to indicators b. c. and d.

4.2 Induction, ongoing learning and development

A robust induction and continuous learning and development program to support the acquisition and maintenance of staff skills and knowledge.
Staff have access to and understand all current policies and procedures relevant to their work.

c. Staff having appropriate supervision and support and participate in internal peer review processes.

d. Staff members are compliant with the professional code of conduct relevant to their particular qualification.

Provide a succinct statement on what this means to your organisation and how you will apply this principle and its indicators.

4.3 Adequate staff resourcing

Caseload management systems that efficiently allocate cases to staff with the experience and skill level to match the worker’s injury, needs and potential case complexity.
Handover practices where cases are reviewed and all relevant parties informed to maintain continuity of care for the worker.

Provide a succinct statement on what this means to your organisation and how you will apply this principle and its indicators.

2. Provider Annual Self-evaluations and other Evaluations as required

To demonstrate ongoing conformance with the Conditions of Approval, an organisation must participate in annual self-evaluations and any independent evaluations as required by the workers’ compensation authority.

Outline the annual self-evaluation procedures and processes that were implemented in the prior 3 year approval period in the context of your organisation’s quality assurance model.

Provide a copy of the most recent self-evaluation report including the quality improvement plan implemented to address the identified non-conformities.

Provide a signed Declaration of Conformity to the Conditions of Approval from your organisation’s most recent annual self-evaluation.

Please provide the name of person(s) who conducted the most recent provider annual self-evaluations on behalf of your organisation, their qualifications and demonstrate how they meet the requirements of an independent evaluator. Please confirm that they were not personally responsible for the aspects of the business that they evaluated.

If your organisation has been required to participate in an independent evaluation by the workers’ compensation authority, please provide a copy of the most recent independent evaluation including the quality improvement plan implemented to address the identified non-conformities.

3. Cases of Workplace Rehabilitation activity

An organisation must demonstrate management of 12 cases of activity consistent with the model of workplace rehabilitation within any workers’ compensation jurisdiction for each 12 month period within the 3 year approval period. (Due consideration will be given to organisations servicing rural and remote areas).

Outline how your organisation has met and will continue to meet this condition.

Please attach case data to illustrate conformance with this requirement.

4. Minimum RTW rate

The workplace rehabilitation provider must maintain the minimum return to work rate as set by the workers’ compensation authority.

Outline how your organisation has met and will continue to maintain the minimum return to work rate.

Please attach performance data to illustrate conformance with this requirement.

5. Safe environment

The workplace rehabilitation provider’s facilities at all locations where services are intended to be provided must provide an accessible and appropriate environment for workers, staff and visitors and comply with local workplace health and safety legislation.

For each location/site describe how the facilities have been and will continue to be accessible and appropriate for all workers, staff and visitors. In your response detail:

the intended hours of operation (for example, business hours and 5 days per week excluding public holidays),
the availability of public transport and/or car parking within or near each location, and
what types of alternatives to stairs are available for workers with mobility impairments.

For each location/site describe how the facilities have complied and will continue to comply with local workplace health and safety legislation.

Appendix 1 - Staff Details

Staff details sheet completed for each location in the jurisdiction where the application is submitted and where workplace rehabilitation services may be delivered.

ORGANISATION:

ADDRESS*:

SITE OR PROVIDER APPROVAL NUMBER, IF APPLICABLE:

DETAILS AS AT DATE:

Name and position title

Qualifications

include: qualification, institution, year of concurrence e.g. B.App Sci. OT Syd Uni – 1991

Years of Workplace Rehabilitation Experience

Basis of
Employment
(e.g. fee-for-service, part time or full-time)

Professional Membership or registration (Type and membership number)

Supervision arrangements for staff with less than 12 months experience.

* Duplicate this page and table for each location in the jurisdiction where the application is submitted. Add more rows to this table if needed to list all staff members.

ORGANISATION:

ADDRESS*:

SITE OR PROVIDER APPROVAL NUMBER, IF APPLICABLE:

DETAILS AS AT DATE:

Name and position title

Qualifications

include: qualification, institution, year of concurrence e.g. B.App Sci. OT Syd Uni – 1991

Years of Workplace Rehabilitation Experience

Basis of
Employment
(e.g. fee-for-service, part time or full-time)

Professional Membership or registration (Type and membership number)

Supervision arrangements for staff with less than 12 months experience.

* Duplicate this page and table for each location in the jurisdiction where the application is submitted. Add more rows to this table if needed to list all staff members.

Appendix 2 - Statement of Commitment to the Conditions of Approval

A reference to the workers’ compensation authority is a reference to the workers’ compensation authority who issued the further Instrument of Approval.

The Conditions of Approval are:

The workplace rehabilitation provider must comply with the Principles of Workplace Rehabilitation.
The workplace rehabilitation provider must ensure that all services are delivered in accordance with the workplace rehabilitation model by persons who hold the minimum qualifications as defined in the Principles of Workplace Rehabilitation and in accordance with service descriptions appropriate to the workers’ compensation authority where the approval is being sought.
The workplace rehabilitation provider’s management structure must include at least one person who holds a rehabilitation consultant qualification outlined in the Principles of Workplace Rehabilitation and who is able to demonstrate 5 years’ relevant workplace rehabilitation experience.
The workplace rehabilitation provider must participate in annual self-evaluations and in independent evaluations as required by the workers’ compensation authority to demonstrate conformance with the Conditions of Approval.
The workplace rehabilitation provider must demonstrate management of 12 cases of workplace rehabilitation within any workers’ compensation jurisdiction for each 12 month period within the 3 year approval period. (Due consideration will be given to providers servicing rural and remote areas).
The workplace rehabilitation provider must maintain the minimum return to work rate as set by the workers’ compensation authority.
The workplace rehabilitation provider must provide data to the workers’ compensation authority consistent with the Conditions of Approval.
The workplace rehabilitation provider must deliver services in compliance to the Code of Conduct for Workplace Rehabilitation Providers.
The workplace rehabilitation provider’s facilities at all locations where services are delivered must provide an accessible and appropriate environment for workers, staff and visitors and comply with local workplace health and safety legislation.
The workplace rehabilitation provider must remain financially solvent.
The workplace rehabilitation provider must notify the workers’ compensation authority in advance, or as soon as practical, if any of the following situations arise and accept that the workers’ compensation authority will review the status of approval and determine whether the proposed arrangements conform with the Conditions of Approval:

the business is sold or the controlling interest in the business is taken over by a new shareholder(s), owner(s) or director(s).
the business changes its trading name or location of premises.
the business supplies or has connections with other suppliers of services within the workers’ compensation industry.
a new chief executive officer or director or head of management is appointed.
there is a major change in the service delivery model and/or staff which may impact on the delivery of workplace rehabilitation services.
there is any other change that affects, or may affect, the provider’s service quality and procedures.
the provider has entered into voluntary financial administration, becomes insolvent or is the subject of bankruptcy proceedings.
there is any professional misconduct proceedings being taken against the provider or any individuals employed or engaged by the provider.

12. The workplace rehabilitation provider must accept that the workers’ compensation authority may:

initiate an independent evaluation at any time during the period of the approval which may involve an evaluation of conformance to the Conditions of Approval, and/or
consult with the relevant professional or industry associations in determining what are reasonable expectations regarding performance, and/or
impose additional requirements, and/or
exchange information with other workers’ compensation authorities on provider performance, and/or
cancel approval status if the above conditions are not met.

I/We have read, understand and accept that I/we must meet and continue to conform to the Conditions of Approval and give consent for sharing of information in relation to this renewal application and the ongoing approval.

I/We understand and are aware that any breach with the terms and conditions of the Conditions of Approval may nullify any renewal application or further Instrument of Approval issued by the workers’ compensation authority in the event the renewal application is approved.

To be signed by the person/s who is authorised to sign this application on behalf of the organisation seeking approval as a workplace rehabilitation provider.

Organisation Name:_____________________________________________________________

Name and Title of authorised signatory:

_______________________________________________________________________

Signature of authorised signatory:

_________________________________________Date:___________________

Name and Title of authorised signatory:

_______________________________________________________________________

Signature of authorised signatory:

_________________________________________Date:___________________

Appendix 3 - Statement of Commitment to the Code of Conduct for Workplace Rehabilitation Providers

I/We have read and agree to conform to the Code of Conduct for Workplace Rehabilitation Providers if approved for renewal as a workplace rehabilitation provider.

I/We understand and are aware that any breach of the Code of Conduct for Workplace Rehabilitation Providers may nullify any renewal application or further Instrument of Approval issued by the workers’ compensation authority in the event the renewal application is approved.

To be signed by the person/s who is authorised to sign this application on behalf of the organisation seeking renewal of approval as a workplace rehabilitation provider.

Organisation Name:_____________________________________________________________

Name and Title of authorised signatory:

Signature of authorised signatory:

_________________________________________Date:___________________

Name and Title of authorised signatory:

_______________________________________________________________________

Signature of authorised signatory:

_________________________________________Date:___________________

Appendix 4 – Comcare renewal requirements

The following Approval Criteria and Operational Standards elements apply to an application by a person for renewal of approval as a rehabilitation program provider (workplace rehabilitation provider).

Complete the following in relation to you as a Comcare provider for the approval period since 1 July 2007 (or from the date of your initial approval if after 1 July 2007).

Criterion 1 – Competence

Please complete Appendix 1- Staff details – to provide Comcare with a current list of providers that have been approved to manage rehabilitation programs under the SRC Act (refer Criterion 1- Competence), and indicate the approximate date of their attendance at Comcare training.
New staff- where a workplace rehabilitation provider has not sought approval by Comcare for undertaking SRC Act work with the applicant please provide documentary evidence to establish that they are competent to provide workplace rehabilitation services subject to Criterion 1.

Include as necessary:

(a) details of attendance at Comcare training (or proposed date)

Certified copies of:

current registration (where applicable)
full professional association membership or eligibility
relevant professional qualification
workplace rehabilitation experience
professional indemnity insurance (if not covered by applicant’s policy).

Please complete Appendix 1- Staff details- for currently approved staff and attach any competency documentation for new staff.

Criterion 3: Financial requirements

2. The provider attests to its financial viability with a reference from an independent, qualified person (such as an accountant or bank manager).

If yes, attach reference.

Please attach documentation.

Criterion 4: Referral base (for renewal of approval)

3. Has the provider had one or more referrals to provide services as a rehabilitation program provider under the Safety, Rehabilitation and Compensation Act 1988 in the past twelve months?

No Please attach explanation.

Yes □ Australian Government or ACT Public Sector
□ Licensed self-insurer. Please attach explanation
□ Other Commonwealth schemes (Seacare or Military Rehabilitation Compensation Commission). Please attach explanation.

Please attach explanation.

Criterion 5: Satisfactory evaluation of performance

Operational Standards- Outcome standards

4. Providers are required to submit to Comcare a summary of the outcome standards achieved for SRC Act work undertaken with Commonwealth Premium paying agencies, Licensed Self-insurers or Military Compensation.

Please attach outcome standard details.

5. Where the provider anticipates that they may have failed to meet any of the outcome standards, the provider may attach a statement explaining the circumstances.

Please attach explanation.

6. Upon receipt of this application and any information supplied by the provider Comcare will assess the provider’s performance against Comcare’s Outcome Standards for the relevant approval period.

Operational Standards -Service standards

7. The provider is required to provide evidence to Comcare that they have met the service delivery standard 2 elements (Return to work management).

Please attach evidence.

8. The provider is required to provide evidence to Comcare that they have met the service delivery standard 3 elements- (Suitable and durable employment).

Please attach evidence.

9. Have all Comcare approved providers employed or engaged by the applicant undertaken Comcare training?

Please attach explanation or evidence.

10. Where the provider anticipates that they may have failed to meet any of the service delivery standards, the provider may attach a statement explaining the circumstances.

Please attach explanation.

Appendix 5- Comcare Agreement and Authorisation

I, _________________________________________________________________

(please print full name)

holding the position of: ______________________________________________,

(please print title)

on behalf of the provider: _____________________________________________

(please print name of provider)

1) certify that the information provided in this renewal application and in support of the renewal application is true and correct. I understand that giving false or misleading information is a serious offence under the Criminal Code

2) agree to advise Comcare as soon as possible of any changes to the information provided in this renewal application

3) authorise relevant persons to provide to Comcare personal information in relation to this renewal application and for the purposes of enabling Comcare to determine whether the provider, a relevant principal or employee of the provider is complying with the Operational standards for rehabilitation program providers (workplace rehabilitation providers) determined under section 34E of the SRC Act. In particular, I understand that this authorises Comcare to seek confirmation of the qualifications, probity and financial standing of the provider, relevant principals and the provider’s employees and the effectiveness, availability and cost of the rehabilitation programs which were provided by the provider, and

If the provider’s approval as a workplace rehabilitation provider is renewed,

4) understand that failure to comply with the Operational standards for rehabilitation program providers (workplace rehabilitation providers) determined under section 34E of the SRC Act or the Criteria for initial approval or renewal of approval of rehabilitation program providers (workplace rehabilitation providers) determined under section 34D of the SRC Act may result in the revocation of approval under section 34Q of that Act

5) agree to advise Comcare in writing within one month of any changes in individuals employed or engaged by the provider to manage return to work plans under the SRC Act, including evidence of qualifications and experience, and

6) agree to Comcare listing details about the provider on Comcare’s website.

Signed ………………………………………… (Applicant)

Date …………………………………………