VICTORIAN WORKCOVER AUTHORITY

WORKCOVER HOUSEHOLD HELP (OCCUPATIONAL

THERAPY) ASSESSMENT REPORT
BACKGROUND INFORMATION
Date of Assessment
Worker
Claim Number
Managing Agent
Date of Injury
Type of Injury
Date of Birth
Gender
Current Work Status
Current Med. Cert.
Employer
Pre-Injury Position
Request Source
Date Request Received
Date of Report
Present (At Assessment)

ASSESSMENT SCOPE
Type of Assessment

Help requested

select one...

[select one]...

Worker has difficulties with

[detail identified tasks that have resulted in the request for services]

Worker is currently receiving

[detail service/s, service provider, when services commenced, hours,

frequency, whether paid for by worker/agent or funded through other means]

In response to this formal request, this assessment was conducted to evaluate the workers ability to perform tasks and maximise their
independence in these activities.

RECOMMENDATIONS
Following this assessment of the workers ability to perform the identified tasks, the following recommendations are outlined below.
(Note: Please refer to the body of the report for background information supporting recommendations).
Comments

[Detail a brief summary and provide any relevant information related to the recommendations listed
below]
RECOMMENDED SERVICES TO MAXIMISE INDEPENDENCE
Provide initial services/Graded Cessation
Reduction
Maintain current services
Service/Task
Week No. (Include graded
reduction plan).
[housework/ gardening]
[eg weeks 1-6]

Education
No service
Hours/ Mins

Frequency

[eg. 2 hours]

[eg. fortnightly]

RECOMMENDED REVIEW DATE(S) FOR SERVICES

Service
[housework/ gardening]

Suggested timeframe for

cessation/ review of services
[eg 3, 6, 12 months]

Suggested actions for review

[eg.: OT review assessment, IMA review with treating medical
practitioner, further medical assessment]

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VICTORIAN WORKCOVER AUTHORITY

RECOMMENDED ASSISTIVE EQUIPMENT TO MAXIMISE INDEPENDENCE
Equipment / Aide
[eg extra long handled toilet
brush]

Strategy for independence

[eg enables worker to clean toilet
without bending]

Impact on need for services

[eg eliminate need for service
provision to complete task]

Supplier
[Supplier, item, code, cost]

RECOMMENDED ADAPTIVE TECHNIQUES TO MAXIMISE INDEPENDENCE

Task
[eg: mowing]

Strategy for independence

[eg: use of self pacing to complete task]

Impact on need for services

[eg cease lawn mowing assistance]

ASSESSMENT INFORMATION SUPPORTING RECOMMENDATIONS

DOCUMENTS REVIEWED
VWA Guidance Material for Occupational Therapists completing WorkCover Household Help (OT) Assessments (mandatory)
VWA Agent Advisory Material (mandatory)
Medical Certificate
Name of Doctor/Practitioner:
Date of Issue:
Other documents (Please list)
Name
Title
Organisation
Date of Report

MEDICAL INFORMATION
Topic
Brief history of injury
Diagnosis
Prognosis
Surgery
Treatment
Medication
Medical restrictions
Current symptoms
Other non work related medical
conditions

Comments

Reported by

LIAISON WITH TREATING MEDICAL PRACTITIONER (TMP)(CONTACT WITH TMP IS MANDATORY)

Name
[eg: name, title]

Date of contact
[Enter date]

Comments
[eg: does TMP support proposed recommendations)

REPORTED PRE-INJURY FUNCTION FOR IDENTIFIED TASK(S)/ ISSUES

Task

Did worker
perform task?

[Detail specific house work,

gardening tasks]

[yes, no,
sometimes]

Comments: Is the worker able to perform the task?

eg If yes/ sometimes, detail frequency, modified techniques/equipment used
If no or sometimes, who else performed task/ how often etc? eg husband
Detail start date & cease date of private services if relevant.
[eg: Enter details]

REPORTED POST INJURY FUNCTION FOR IDENTIFIED TASK(S)/ISSUES

Task

[Detail specific house work,

gardening tasks]

CONSULTANT SIGNATURE

Is worker currently Comments: Is the worker able to perform the task?

performing task?
eg If no or sometimes, assess the workers ability to perform task. Where possible
provide education on adaptive techniques, assistive equipment etc
If no or sometimes, who else performs task/ how often eg children
[yes, no,
[eg: Enter details]
sometimes]

WORKCOVER HOUSEHOLD HELP (OCCUPATIONAL

THERAPY) ASSESSMENT REPORT
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VICTORIAN WORKCOVER AUTHORITY

TASKS CURRENTLY COMPLETED BY HOUSEHOLD HELP SERVICES

Task
[Detail specific house work,
gardening tasks]

Hours/frequency
[Enter details]

Comments
[Include relevant details ie start date of services, services provided]

CURRENT PRESENTATION (COMMENT AS RELEVANT TO IDENTIFIED TASKS)

Title
Height
Weight
Range of movement/ Hand
dominance
Sitting tolerance
Standing tolerance
Walking tolerance
Lifting capacity
Endurance
Ability to perform other tasks
(not included in assessment
scope)
Psychological issues

Comments
[Enter details if relevant ie impacts on ability to complete tasks]
[Enter details if relevant ie impacts on ability to complete tasks]
[ie as relevant to identified tasks]

Reported

Observed

[Minimum/ maximum limits]

[Minimum/ maximum limits]
[Minimum/ maximum limits]
[Enter details]
[eg: activity tolerances]
[eg other personal and domestic tasks, driving, social activities, sport etc] ]

[Enter details]

OBSERVATIONS AND CORRELATION BETWEEN OBSERVED AND REPORTED DATA

[Enter details: formal & informal observations, self reported status of worker, THP opinion, medical reports and documents etc]

PERSONAL/HOUSEHOLD CIRCUMSTANCES
Topic
Detail relationship status of worker
Ability of occupants to assist with
household tasks.
Detail number & age of children
Details other people living in the house
not included above:
Detail other people who provide
assistance in tasks but do not live at
house.
Detail any house members who have a
disability or illness etc? If so, detail
level of assistance required, frequency/
by who:

Comments
[Enter details]
[Enter details]
[Enter details]
[Enter details]
[Enter details]

[Enter details]

DETAILS OF THE HOME ENVIRONMENT

Topic
Pre-injury Home (if relevant)
Current home type
Number of bedrooms
Number of bathrooms

Comments
[detail if there has been any change in the worker's home environment since the injury]
[Enter details]
[Enter details]
[Enter details]

Number of living areas

Type of flooring carpet/ tiles
Access to home
General presentation
Does the worker own safe & appropriate
standard equipment? If no, what did
they use before their injury?
Dose the worker have any assistive
equipment?

[Enter details]
[Enter details]
[Enter details of internal and external access including steps]
[Enter details eg presentation of house/ garden, garden setup]
[Enter details]

CONSULTANT SIGNATURE

[Enter details]

WORKCOVER HOUSEHOLD HELP (OCCUPATIONAL

THERAPY) ASSESSMENT REPORT
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VICTORIAN WORKCOVER AUTHORITY

SUMMARY OF TASKS AND RELEVANT COMMENTS
Upon completion of the Household Help (OT) Assessment the following is noted:
Task
Workers Comments
[Detail issue]

[Detail issue]

[Detail issue]

Occupational Therapists Comments

ADDITIONAL COMMENTS
[Detail any additional comments. N/A if not applicable]

This report has been completed for the consideration of the agent. If you wish to discuss this report or require further information, please
contact the author on [Enter phone number].

[Enter name]
Occupational Therapist
B. App. Sc. (O.T.)
cc:

CONSULTANT SIGNATURE

WORKCOVER HOUSEHOLD HELP (OCCUPATIONAL

THERAPY) ASSESSMENT REPORT
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