Certificate of Capacity - no barcode

Health providers fill in this form to describe a person's injury, illness and capacity to work.
Last updated

Feb 2015

Reading level


File Type and Size

PDF, 617.75 kB

Document Length

2 pages

What it contains

This form is for health providers to communicate with employers and case managers about an injured person’s ability to work. Information to be completed by certifiers about the injured worker includes:

  • personal details
  • clinical diagnosis
  • capacity assessment for work
  • certification for pre-injury employment, capacity for employment or no capacity for employment
  • treatment plan
  • certifier declaration
  • worker declaration

The worker and the certifier must both sign declarations at the end.