Certificate of capacity example

Here’s an example of a certificate of capacity that is used in Victorian WorkCover matters.

Below, we detail each section that you’ll find on a certificate of capacity.

If you’re unfamiliar with certificates of capacity, you can read about them here.

1. Worker details

In this section, your basic details will need to be filled in.

Your name, address, WorkCover claim number (if you don’t know your claim number, here’s how you can locate it). If your claim number isn’t known, the date of injury can be listed.

2. Diagnosis

In this section, the person certifying you needs to indicate the date they assessed you.
They will also need to indicate what their clinical diagnosis is.

For example, it might be ‘right shoulder injury’ or ‘shoulder bursitis’.

3. Capacity assessment

This is an important section on the certificate.

In this section, the person certifying you needs to indicate what restrictions there might be given your injury.

If you have a physical injury, then the person certifying you will need to fill in this section:

For each of those physical functions – eg; sit, stand/walk, squat, kneel etc – the person certifying you will need to indicate whether you can perform those physical functions, whether you can perform those physical functions with modifications, or whether you’re not able to perform the relevant physical function.

If there is addition comments required – such as ‘no lifting above 10kg’ or ‘no repetitive bending’ these can be written here.

If you have a psychological injury, then the person certifying you will need to fill in this section:

For each of the mental health functions listed there, the person certifying you will need to indicate whether a particular function is not affected or affected.

Again, to the right of this is a box for the person certifying you to provide additional comments in relation to your capacity.

Any further funcitonal considerations or additional comments – for example: “taking opiod medication so needs to avoid using heavy machinery” can be noted in this section.

If there are any comments the certifyer wants to make in relation to your work environment, they can do so here.

An example might be, if someone has contact dermatitis because of an allergic reaction to cleaning chemicals, the person certifying may note “need to avoid aggravating chemicals and avoid working in hot conditions.”

4. Certification section

This is another important section of the certificate of capacity.

Here, the person certifying you needs to indicate whether you have a capacity for full, unresitrcted duties, suitable or modified duties, or no capacity for work at all.

They will need to indicate a date that this capacity starts from. And in the event they certify you as having a capacity for suitable or modified duties, or no capacity for work at all – they will need to indicate a date that the certification goes to.

In this section, the person certifying you is asked to indicate when they estimate you might be able to return to work (this only needs to be filled out if you’re certified as having a capacity for no work – and if the certifyer can’t answer it because it is unknown, it can be left blank).

5. Treatment plan

The person certifying you can provide some information regarding your treatment plan.

That is, injury management, what strategies will they implement to increase capacity for work, address return to work barriers, and/or prevent recurrence/aggravation of injury.

An example might be ‘referral to a specialist doctor’ or ‘review in a month with a view to reducing reliance on pain killing medication’.

6. Certifier declaration

In this section, the person that is certifying you will need to note their details and will need to sign the certificate.

They’ll also need to indicate the date the certificate is being completed.

7. Worker declaration

In this section, you as the worker will need to indicate whether, at any time since the last certificate of capacity was provided, you have engaged in any voluntary work or in any form of employment or self employment for which you have received or been entitled to receive payment in money or otherwise.

You’ll need to indicate either yes or no.

Keep in mind however that this is a broad definition.

Say that you’ve been doing dog walking on weekends and you’ve been getting paid in cash.

This should mean that you’d tick yes on the form. And then you’d need to provide details in this section as to the work you’ve been performing.

Underneath that, you’ll need to sign and date the certificate.