Case Study: Return to Work Plan for Georgia Kelly's Injury Claim

This case study presents a return-to-work (RTW) arrangement template designed for Georgia Kelly, an administration assistant with a WorkSafe claim for a left wrist injury. The template outlines pre-injury work details, including her job title, hours, and location at ABC Logistics. It details the duties Geor...Read More

Return to Work Toolkit
Return to Work
Arrangements Template

Return to Work Arrangements Template
Includes Proposed Suitable or Pre-Injury Employment
Details
These return to work arrangements are for:
Name of worker WorkSafe claim number
Georgia Kelly TBC
Pre-Injury work:
Job title Days/hours of work
Administration assistant 38 hours per week
Location
23 Brunton Avenue, Derrimut, 3030
Name of employer
ABC Logistics
Return to Work Arrangements
Duties or tasks to be undertaken
Describe the specific duties and tasks required. Include any physical and other requirements, e.g. lifting, sitting, rotation
of tasks, etc.
Georgia is entrusted with the responsibility of assisting the administrative staffs in managing the administration.
Specifically, she is to do file work by sitting on the computers for long hours. The data entry work involves sitting and at
other times, she needs to stand for taking notes from the administrative staffs.
Workplace supports, aids or modifications to be provided
Describe workplace supports, aids or modifications, e.g. rest breaks, buddy system, special tools, equipment, training,

etc.
Georgia would get the support of a helper for lifting heavy files. He would always be there for assisting Georgia when
she needs to take files from one place to other. However, there would be breaks in between, which would provide rest
to her hands.
Specific duties or tasks to be avoided
Describe the specific duties and tasks that are to be avoided or restricted, e.g. no loading pallets, tasks that are only to
be undertaken with the assistance of another worker.
As per the doctor’s prescription, Georgia is restricted from typing activities.

Medical restrictions
Describe the restrictions on the most recent Certificate of Capacity or from other sources, e.g. phone call with the
worker’s doctor or healthcare provider, other medical information provided by the WorkSafe Agent. From what date or
period(s) do these restrictions apply?
Restraining from typing work
Working for 4 hours per day . 5 days in a week
Restrictions in place until 16/10/10
Dr Yang suggested an increase in the working hours in the upcoming preview. This would be dependent on Georgia’s
progress with her physician and resuming work under the supervision of the employer.
Hours of work
It is recommended that reduced hours are gradually increased where appropriate.
Week 1 Mon Tue Wed Thu Fri Sat Sun Total p/w
5/10/10 8am-
12pm
8am-
12pm
8am-
12pm
8am-
12pm
8am-
12pm
Week 2 Mon Tue Wed Thu Fri Sat Sun Total p/w
12/10/10 8am-
12pm
8am-
12pm
8am-
12pm
8am-
12pm
8am-
12pm
Week 3 Mon Tue Wed Thu Fri Sat Sun Total p/w
Week 4 Mon Tue Wed Thu Fri Sat Sun Total p/w
Work location
(address, team, department)
Warehouse. 23 Brunton Avenue.
Derrimut Start date: 5/10/10
Supervisor
(name, position, phone number) Brad Westoon Review date: 16/10/10
Prepared by
(name, position, phone number) Ivor Sutcliffe, RTW Coordinator Date prepared: 2/10/10
Signature of key people involved
Worker – I will participate in these return to work arrangements.

Name Phone Signed Date
Georgia Kelly 0241 543 876
Return to Work Coordinator – I will monitor and review these return to work arrangements.
Name Phone Signed Date
Ivor Sutcliffe 0994 888 777
Supervisor – I will implement these return to work arrangements in the work area.
Name Phone Signed Date
Brad Weston 0443 756 123
Doctor – These return to work arrangements are consistent with the worker’s capacity.
Name Phone Signed Date
Dr Yang 9949 0000
Notes/additional information
If there is any additional information you wish to include in this form, please attach any supporting documentation e.g.
medical reports, position description, photos etc.
Georgia can be provided with chairs, which are slightly lifted. This would maintain the balance between her body and
computers/laptops. Along with this, the availability of the helper needs to be ensured for averting any illegal instances.