What it contains

This form can be used by WorkSafe agents, prescribing therapists and occasionally hospitals to order equipment. Details to be completed in the form include:

  • the equipment order details, including the equipment category, service and supplier details, and prescribing therapists and medical practitioner details
  • the injured employee’s details
  • details about the equipment or repairs and maintenance needed

At the end of the document, there is also information about how WorkSafe collects personal information.

Important: Please download this PDF to your computer. You can fill it in using Adobe Reader but it will not save if you attempt to fill it in using your web browser.

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