Referral for household help services needs assessment

What it contains

This form must be completed by WorkSafe authorised agents and self-insurers. It must be provided to an occupational therapist (OT) when referring a worker for a Household help services needs assessment (HHSNA). A HHSNA evaluates a worker’s ability to manage cleaning and gardening responsibilities after their work-related injury or illness.

This form should be used following receipt of a Request for household help services form from a worker's treating health practitioner. It can also be used after receiving other relevant supporting documentation, such as a Household help request: Worker declaration.

This form provides OTs with a clear scope for conducting the assessment. This will result in the return of quality reports to agents and self-insurers to support their decision-making processes.

More information about completing this form and about the associated fees for accepting a referral can be found in the form's instructions and in the Claims manual.