Household help request: Worker declaration

What it contains

This declaration must be filled out by the injured worker looking to access household help services.

WorkSafe is committed to improving outcomes for injured workers. This information is essential for your agent/self-insurer/case manager to make decisions about your eligibility for household help services. Please provide as much detail as possible when responding.

To apply for household help, you need:

• A current and complete Request for household help services form. This may be completed by your physiotherapist, osteopath, chiropractor or medical practitioner/GP. It is advised that you book an appointment to have this form completed.
• To complete this Worker’s declaration form, and return it to your agent/self-insurer/case manager.
• Your treating health practitioner will need to review this form when they complete your referral.