Equipment prescription form

Health providers can use this form to request equipment for injured workers.
Last updated

Jan 2020

Reading level


File Type and Size

PDF, 154.66 kB

Document Length

4 pages

What it contains

Service providers can use this form to request wheelchairs, pressure cushions, powered conversion kits, hoists, scooters, beds, mattresses, standing frames, tilt tables, large exercise equipment, lounge chairs and customised chairs.

The form should also be used to request repairs or modifications to this equipment.

Details to be completed in the form include:

  • the injured employee's details
  • equipment details, including if it’s to be reissued, replaced, modified or purchased
  • the employee's work-related injuries and medical history
  • what type of equipment is recommended and how it will benefit the employee
  • It is expected that prescribing therapists conduct trial of items from the Equipment List (if available) with WorkSafe equipment contracted suppliers before recomending any non-contracted items from an alternative supplier in line with the WorkSafe Equipment and related services policy
  • anticipated maintenance and repair, training requirements and the treating therapist's details

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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