Workcover Referral

Worker Name *

First Name

Last Name

Worker DOB

MM

DD

YYYY

Date of Injury

MM

DD

YYYY

Risk Assessment

Tick if answer is YES and Community Based Program Required

Is there safe vehicle access and parking?

Is there mobile phone coverage?

Can animals be restrained?

Is there any alcohol/drug use in the house including paraphernalia?

Is there a history of violence within the house?

Are there any weapons/dangerous objects in the house?

Is anyone in the house living with an infectious disease?

Are there any religious, gender, or cultural preferences that we should be aware of?

Is a translator required at the assessment?

Has the person displayed behaviours of concern?

Does the person have a history of incarceration?

Does the person have unmedicated mental illness?

Are there other safety concerns that we should be aware of and that you would like to discuss?