This application form must be lodged by organisations who wish to be approved to deliver workplace rehabilitation services within the NSW workers compensation scheme. Applicants must read and use the workplace rehabilitation provider approval framework to prepare their application.
Application checklist
- Before beginning this application, please ensure you have all the documentation and attachments that have been requested ready to upload and you are using the latest version of your web browser
- Please save all your attachments with your trading name and description as the file name - no longer than 50 characters or 2MB per attachment
- Once you have completed this application, a copy will be emailed to the nominated contact person. It is advised that you review the email to ensure that all of your documents have uploaded. If they haven't, please lodge a further application with your contact details and any missing documents.
If you have any questions or require assistance please contact 13 10 50 or email: [email protected]
Please to the attached staff sheet
Section 1: Applicant details
Contact person (used by SIRA to contact provider)
Organisation details
Organisation head office street address (must NOT be a PO Box)
Organisation head office postal address
Note: a completed copy of the Performance data sheet must be attached for each site.
Parent organisation details (if applicable)
If yes, complete the following section
Parent organisation head office street address (must NOT be a PO Box)
Name and position of person(s) authorised to sign this application on behalf of the organisation
Previous applications
Conflict of interest1
Professional misconduct or criminal proceedings
Insurance currency
In the context of workplace rehabilitation service provision, please attach current copies of your organisation’s certificates of currency for the following.
Professional indemnity insurance
Public liability insurance
Workers compensation insurance
Section 2:
Service stream confirmation
Conforming to the Conditions of approval
An application must demonstrate how the applicant will conform to the Conditions of approval. Please use this space to outline the documents you are attaching to your application demonstrating how your organisation will conform with the Conditions of approval.
Separating your response by:
Condition 1 – As per table 2.1: please outline your organisation’s service delivery model demonstrating your conformance with Condition 1 – Services must be delivered in accordance with the approved service delivery model.
Condition 2 – As per appropriately qualified staff sheet.
Condition 3 – table 2.3 please outline your organisation’s conformance with mandatory requirements
for Condition 3 – Quality management systems and governance.
Condition 4 – please provide data prescribed by SIRA Table 2.4..
Payment
Use your provider name as reference, submit payment of the application fee ($2,000) to SIRA (this application fee is GST free):
- BSB: 032 001
- Account number: 112 713
Please provide an email confirmation to SIRA with reference number once payment has been made to [email protected]
SIRA is unable to accept credit card payments or provide an invoice.
Submission
Note: When you select the ‘Submit’ button below, it will take few minutes to run the necessary security scans. On completion, the form will change and you will be sent an email.
Footnote
1. Where there is either a professional or personal relationship between the proposed new employer and the worker, or a business relationship between any of the parties involved which may give rise to a conflict of interest, the provider should outline why the program should be approved. This should include the strategies that will be implemented to address the conflict of interest. The application will need to be endorsed by SIRA to proceed if there is a conflict of interest identified.
