Complete this form to apply for approval as an injury management consultant in the NSW workers compensation scheme, under section 45A(2) of the Workplace Injury Management and Workers Compensation Act 1998 (1998 Act).
Instructions
Complete all relevant sections and attach evidence where indicated.
Required fields are marked with an asterisk (*).
Before starting, make sure you have everything you need to complete your application. You cannot stop or save an application.
Save all attachments (ready to upload) with your name and description as the file name - no longer than 50 characters or 2MB per attachment (Word, PDF or JPG).
What you will need:
- AHPRA registration number
- Current resume
- Two referees who are able to complete a written statement providing detail to support:
- your working knowledge of the NSW workers compensation scheme, and
- your high-level communication and negotiation skills.
Privacy
Information you provide will be managed in accordance with the SIRA Privacy Statement.
Your name in Section 1 and all information provided in Section 2 will be made publicly available on the SIRA website.
More information
If you have any questions or require assistance, call 13 10 50 or send an email.
1. Your details
2. Health practitioner details
This information will be published with your name on the SIRA website.
2.1 Practice details
Practice 1
Practice 2
Practice 3
Additional practice locations
If you have more than three practice locations, please include the details of additional locations on a separate document and attach below.
2.2 Special interest area
3. Eligibility requirements
3.1 AHPRA registration
Practitioners are NOT eligible for approval if they have any conditions, undertakings, reprimands, limitations or restrictions on their registration as a result of a disciplinary process, or are subject to supervisory requirements, or have any other provisions that may adversely impact performance in the role.
3.2 Five years relevant clinical experience
Practitioners are required to have at least five years relevant clinical experience, including the treatment and/or management of work-related injuries
3.3 Have been in clinical practice for 8 hours per week within the last three years
3.4 Demonstrated working knowledge of the NSW workers compensation scheme and treatment and/or management of work-related injuries
Note: This criterion will also be assessed via the provision of referee statements. You are required to provide two referees at 3.6 in this application.
3.5 High level communication and negotiation skills
Note: This criterion will also be assessed via the provision of referee statements. You are required to provide two referees at 3.6 in this application.
3.6 Referees
Provide two referees who are able to complete a written statement providing detail to support:
- your working knowledge of the NSW workers compensation scheme, and
- your high-level communication and negotiation skills.
SIRA will provide each referee with a Referee’s Statement to complete. Please ensure they are aware and have provided consent for you to provided their details to act as your referee.
Please choose your referees from the following categories:
Note: Do not provide the name of a colleague/peer, your employer or a representative from a medicolegal organisation. These are not suitable referees.
Referee 1
Referee 2
3.7 Other criteria
When reviewing an application, SIRA may consider other relevant information. This may include if the applicant has:
- been subject to a complaint made to insurance, compensation or health authorities, government agencies or statutory bodies regarding the applicant’s conduct in the last 10 years
- had any demonstrated breach of legislation, guidelines or fee schedules in any statutory insurance compensation system in any Australian jurisdiction in the last 10 years
- any pending criminal charges or any criminal convictions
- demonstrated behaviour that may affect the applicant’s ability to undertake the role with impartiality and fairness or may affect the integrity of the workers compensation scheme.
4. Acknowledgement and declaration
I acknowledge and understand that:
- failure to provide information requested by SIRA within the required timeframes, to assist SIRA in determining this application, may result in the application not being assessed
- approval as an injury management consultant by SIRA does not guarantee any work in the role
- by submitting an application, I consent to SIRA collecting information from other persons or bodies, including third parties, to determine whether I meet the eligibility requirement
- the information provided will be used to assist SIRA establish, monitor and review registration and membership details upon application and throughout the approval period, and
- I must notify SIRA within seven days if I become aware that information provided in this application, including the declaration below, was incorrect or incomplete.
I declare that:
- The information provided in this application is true and correct.
- I am the person named in the application and attached documents.
- I have the relevant insurances required as part of my AHPRA registration as a medical practitioner with appropriate coverage for my area(s) of practice.
- I have read and understood:
- if my application is successful, I agree:
