Certificate of capacity for work - legislation act gov 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin with Part A, entering the patient's first name, last name, and date of birth. Fill in the current occupation and the date assessed.
3. Provide details on clinical symptoms or diagnosis, followed by comments on physical and mental capacity. Include any other issues impacting recovery or return to work.
4. Indicate the recommendation for work fitness by checking the appropriate box and providing relevant dates. If applicable, detail any graduated return to work, modified duties, reduced hours, or workplace adjustments.
5. In Part B, enter the claim number and details regarding when the patient was first seen. Specify if the injury is new or an aggravation of a pre-existing condition.
6. List any relevant factors affecting recovery and request a return-to-work case conference if necessary.
7. Complete Part C by affixing your practice stamp or providing contact details along with your signature and date.

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