**ACC7980**
**Back to Work – Completion Report**
"A Back to Work (BTW) provider completes and submits this form to ACC on the date the client is discharged from the BTW programme."
"Submit this form to the ACC contact person or claims@acc.co.nz"
(All checkbox options throughout this form must always appear in the output. Never omit any checkbox options. If a checkbox option is not explicitly mentioned in the transcript, contextual notes, or clinical note, leave it as '[ ]'. Do not remove or hide any checkbox options under any circumstances.)
**1. Client details**
**Client name:** [client's full name] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
**Claim number:** [client's ACC claim number] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
**Date of injury:** [client's date of injury] (Print the date in DD/MM/YYYY format. Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
**2. Supplier Contact details**
**Supplier company name:** [supplier company name] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
**Service Delivery Company name:** [service delivery company name] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
**Lead Provider name:** [lead provider's full name] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
**Lead Provider phone:** [lead provider's phone number] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
**Lead Provider email address:** [lead provider's email address] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
**3. Completion Outcome**
(Mark with '[x]' in the 'Outcome Achieved' column based on information explicitly mentioned in the transcript, contextual notes, or clinical note. You may mark more than one of the following outcomes. All rows must always appear in the output. Do not omit any rows. If an outcome is not explicitly mentioned, leave its 'Outcome Achieved' column as '[ ]'.)
| Outcome | Outcome Achieved |
|---|---|
| Rehabilitation complete for the pre-injury role and this role is now considered sustainable | [ ] (Mark with '[x]' if rehabilitation is complete for the pre-injury role and the role is now considered sustainable. Leave '[ ]' if not explicitly mentioned.) |
| The client is considered work ready for vocational independence | [ ] (Mark with '[x]' if the client is considered work ready for vocational independence. Leave '[ ]' if not explicitly mentioned.) |
| Obtained employment | [ ] (Mark with '[x]' if the client has obtained employment. Leave '[ ]' if not explicitly mentioned.) |
| No outcome achieved | [ ] (Mark with '[x]' if no outcome was achieved. Leave '[ ]' if not explicitly mentioned.) |
Pre-Injury role: [client's pre-injury role title] (Only include if Rehabilitation complete for the pre-injury role and this role is now considered sustainable is marked '[x]' in the table above. If not marked '[x]', omit placeholder, retain heading and leave blank. Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
Hours per week: [hours per week of obtained employment] (Only include if Obtained employment is marked '[x]' in the table above. If not marked '[x]', omit placeholder, retain heading and leave blank. Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
Job Type/Role: [job type or role of obtained employment] (Only include if Obtained employment is marked '[x]' in the table above. If not marked '[x]', omit placeholder, retain heading and leave blank. Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
Other details: [other details about obtained employment] (Only include if Obtained employment is marked '[x]' in the table above. If not marked '[x]', omit placeholder, retain heading and leave blank. Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
**4. Rehabilitation**
"Confirm the rehabilitation completed to achieve and confirm the outcome above"
_"Include the vocational training and rehabilitation provided to the client and the date it was completed. Also include any previously recommended vocational training and rehab not provided and the reason why"_
[rehabilitation completed to achieve and confirm the outcome including vocational training and rehabilitation provided, dates completed, and any previously recommended vocational training and rehabilitation not provided with the reason why] (Describe the rehabilitation completed, including the vocational training and rehabilitation provided to the client and the date it was completed. Also include any previously recommended vocational training and rehabilitation not provided and the reason why. Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
List the work types from the IOA/IMA that the client is now considered work ready for
[work types from the initial occupational assessment or initial medical assessment that the client is now considered work ready for] (Only include if The client is considered work ready for vocational independence is marked '[x]' in section 3. If not marked '[x]', omit placeholder, retain heading and leave blank. Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
List any additional work types (not from the IOA/IMA) that you have identified and consider the client is work ready for
[additional work types not from the initial occupational assessment or initial medical assessment that the client is considered work ready for] (Only include if The client is considered work ready for vocational independence is marked '[x]' in section 3. If not marked '[x]', omit placeholder, retain heading and leave blank. Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
List any work types assessed as medically sustainable (or likely to be) in the IMA that the Client is **not** considered work ready for
[work types assessed as medically sustainable or likely to be in the initial medical assessment that the client is not considered work ready for] (Only include if The client is considered work ready for vocational independence is marked '[x]' in section 3. If not marked '[x]', omit placeholder, retain heading and leave blank. Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
If no outcome was achieved, please give details as to why (including any partially achieved outcomes):
[details as to why no outcome was achieved including any partially achieved outcomes] (Only include if No outcome achieved is marked '[x]' in section 3. If not marked '[x]', omit placeholder, retain heading and leave blank. Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
Does this client require any more assistance from ACC?
(Mark with '[x]' based on information explicitly mentioned in the transcript, contextual notes, or clinical note. Only one of the following options must be marked with '[x]'. Do not mark more than one. Do not omit any options.)
[ ] Yes (Mark with '[x]' if the client requires more assistance from ACC. Leave '[ ]' if not explicitly mentioned. These 2 options are mutually exclusive — only one must be marked with '[x]'. Do not omit any options.)
[ ] No (Mark with '[x]' if the client does not require more assistance from ACC. Leave '[ ]' if not explicitly mentioned. These 2 options are mutually exclusive — only one must be marked with '[x]'. Do not omit any options.)
If yes, what assistance is required?
[assistance required from ACC] (Only include if the client requires more assistance from ACC question is marked '[x]' for Yes. If marked '[x]' for No, omit placeholder, retain heading and leave blank. Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
Any additional comments:
[any additional comments] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
**5. Provider declaration and signature**
"I declare the information provided by me on this form is, to the best of my knowledge, accurate and complete."
**Provider name:** [provider's full name] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
**Provider discipline:** [provider's clinical discipline] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
**Signature:**
**Date:** [date of signature] (Print the date in DD/MM/YYYY format. Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
"When we collect, use and store information, we comply with the Privacy Act 2020 and the Health Information Privacy Code 2020. For further details see ACC's privacy policy, available at www.acc.co.nz. We use the information collected on this form to fulfil the requirements of the Accident Compensation Act 2001."
**Items for Clinician Review**
[checklist of items requiring clinician verification before finalising] (Print each flagged item on its own line beginning with '-' (bullet point), followed by the section name and a brief description of what the clinician needs to verify. Flag any content where review is warranted before sign-off. Examples of what to flag include: identity and demographic details that were unclear, partial, or potentially misheard, such as patient name spelling, NHI number, ACC claim number, date of birth, contact details, or address; dates that were spoken partially or ambiguously, such as "the third of the third" without a year, "last Tuesday" without an explicit date, date of injury, date of first treatment, date of assessment, or follow-up review date; mechanism of injury described vaguely or incompletely, such as "twisted awkwardly" without direction or load, "fell" without specifying surface or height, or a mechanism inferred from outcome rather than stated; diagnoses lacking specificity, such as body region without side, "shoulder pain" without specifying which shoulder, a general diagnosis without laterality, chronicity, or grade, or a working diagnosis where a definitive one is expected; numerical values that were partial, unclear, or potentially misheard, such as pain scores, range of motion in degrees, strength grades, blood pressure readings, medication doses, dosing frequencies, sessions per week, hours per day, percentage ratings, or impairment ratings; codes or classifications mentioned but not clearly stated, such as Read codes, ICD codes, work capacity percentages, whole-person impairment ratings, or ACC-specific category codes; provider details that were not fully stated, such as referring practitioner name and provider number, signing clinician designation, ACC provider ID, or supplier ID; functional capacity or independence ratings where the spoken value was indistinct, where multiple ratings were given without clarifying which was final, or where a rating was implied but not explicitly stated; return-to-work plan elements partially captured, such as target return date, hours per day, days per week, modified duties, lifting or postural restrictions, graduated return phases, or review date; treatment plan details with potential ambiguity, such as medication name, dose, frequency, route, or duration; therapy modality, session count, frequency, or review point; equipment or aid prescriptions without size, model, or supplier; clinical content inferred from context rather than explicitly stated, such as an assumed diagnosis based on described symptoms, an inferred mechanism, an inferred prior medical or surgical history, or an inferred medication based on a condition; conflicting or contradictory information across the transcript, contextual notes or clinical note, such as different dates of injury given at different points, conflicting body regions, conflicting laterality, or conflicting medication details; sections of the ACC form where expected information was not mentioned at all, such as consent confirmation, declaration date, clinician signature, mandatory demographic fields, or required outcome ratings; abbreviations, acronyms, or shorthand terms used by the clinician that may have multiple meanings or were not clearly resolved during the consultation; and any quoted values where the audio was likely affected by background noise, simultaneous speech, or the patient and clinician disagreeing on a detail. For each flagged item, name the section of the form it belongs to and describe the issue in one short sentence. If no items require review based on the transcript, contextual notes or clinical note, print "None flagged." beneath the section heading. Always include this section heading.)
(Always retain all section and sub-section headings in the output, regardless of whether content is available to populate them. If no information is explicitly mentioned for a given section or sub-section, leave the area beneath the heading blank but never remove the heading itself.)
