Equipment prescription form

What it contains

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

It is expected that the prescribing health professional conducts trials of equipment items with WorkSafe equipment contracted suppliers before recommending any non-contracted items from an alternative supplier, in line with WorkSafe’s Equipment and related services guidelines.

The 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.
• If non-contracted equipment is recommended, the Equipment Prescription Form must include clinical rational of why equipment from WorkSafe’s Contracted Equipment Suppliers does not meet the worker’s needs and why the recommended item is reasonable and necessary.

A valid quote for the recommended equipment must be submitted with the correctly completed equipment prescription form.