Equipment prescription form

What it contains

This form should be completed for all requests to supply, hire or modify equipment for workers other than the following.

• Equipment requested with the Hospital direct order form.
• Equipment provided under WorkSafe’s Small stock policy.
• Adaptive household equipment, which is generally prescribed using a Household help services needs assessment form.

The Equipment prescription form should include the following.

• The worker's personal details.
• Equipment details. Indicate if the request is for purchase, hire, replacement or modification.
• Details of the worker's work-related injuries and medical history.
• The type of equipment recommended and how it will benefit the worker.
• Details of any anticipated maintenance and repair.
• Details of any training requirements and the prescribing health professional’s details.
• Details and outcomes of equipment trials. It is expected that the prescribing health professional will conduct trials of equipment items with WorkSafe equipment contracted suppliers before recommending any non-contracted items from an alternative supplier. This is in line with WorkSafe’s Equipment and related services guidelines.
• If non-contracted equipment is recommended, the Equipment prescription form must include clinical reasons why equipment from WorkSafe’s contracted equipment suppliers does not meet the worker’s needs. It must also state why the recommended item is reasonable and necessary.
• A valid quote for the recommended equipment.