ACC 7431
Back to Work – Initial and Progress Report
A Back to Work (BTW) provider completes this form to update ACC on a client's progress towards their return-to-work rehabilitation.
Submit this form to the ACC contact person or claims@acc.co.nz
1. Report stage
[x] Initial — Complete sections 1 to 7 and sign section 9
[ ] Progress (number): — Additionally complete section 8 and sign section 9. Only the current progress report is required.
Date of this report: 22/05/2026
2. Client details
Client name: Owen Murray
Claim number: 10082147
Date of injury: 22/09/2025
3. Supplier Contact details
Supplier company name: Southern Vocational Rehabilitation Services
Service Delivery Company name: Southern Vocational Rehabilitation Services
Lead Provider name: Aroha Tane
Lead Provider phone: 03 477 8821
Lead Provider email address: a.tane@svrs.co.nz
4. Overall objectives
What is the overall objective specified in the referral? You may tick more than one
[x] Regain fitness for Pre-injury Work Role
Please also complete section 6a
[x] Work readiness for Vocational independence (VI)
Please also complete section 6b
[ ] Obtain employment
[ ] Other
Comment:
Owen would like to return to his pre-injury role as a chainsaw operator and forestry contractor. The clinical team supports a parallel pathway: exploring vocational independence options should the demands of forestry prove unsustainable following his ACL reconstruction and lateral meniscectomy. The final pathway will be determined at the 12 week functional re-evaluation.
5. Relevant contacts involved in the client's rehabilitation
Name of personRoleEmailPhoneDate of contactMr Henry WilsonOrthopaedic Surgeonh.wilson@otagosurg.co.nz03 477 556330/09/2025Dr Pita NgataGeneral Practitionerp.ngata@silverpinemed.co.nz03 466 291214/05/2026Karen MurraySpouse and Support Person-027 521 449812/05/2026Aroha TaneLead Provider, Vocational Rehabilitation Consultanta.tane@svrs.co.nz03 477 882112/05/2026
6. Initial assessment
Date of initial assessment: 12/05/2026
Outcome target date on referral: 30/09/2026
Outcome target date following assessment: 30/09/2026
If applicable, the reason for the new target date:
<u>Assessment summary of the Client</u>
Brief injury history
Owen sustained a right knee injury on 22/09/2025 while operating a chainsaw in steep terrain in the Catlins forestry block. He slipped on a wet log and fell; full PPE was intact and there was no chainsaw laceration. MRI on 26/09/2025 confirmed an ACL rupture, lateral meniscal tear, and a Grade II MCL sprain. He underwent arthroscopic ACL reconstruction (hamstring autograft) and lateral partial meniscectomy on 30/09/2025 under Mr Henry Wilson at Otago Orthopaedic Surgery. Post-operative recovery has been slower than anticipated, with persistent effusion and quadriceps inhibition requiring an additional two months of structured physiotherapy before weight-bearing strengthening commenced.
Functional presentation / limitations
Now 8 months post-surgery. Owen walks on level ground for 30 to 40 minutes without significant symptoms. Stair tolerance is limited; he descends one step at a time. Pain on prolonged standing beyond 2 hours. Reduced confidence with uneven terrain and steep slopes. Right quadriceps strength is approximately 70% of the left on manual muscle testing. Single leg hop test at 60% of the unaffected side. Unable to kneel for sustained periods or squat below 90 degrees of knee flexion without discomfort. KOOS (Knee injury and Osteoarthritis Outcome Score) sport and recreation subscale: 38/100.
Medical certificate status
Currently on a fully unfit medical certificate from his GP, Dr Pita Ngata, last reviewed 14/05/2026 and due for re-review 14/07/2026.
Biopsychosocial, cultural, and other factors (including barriers)
Owen is the family's primary income earner and his wife Karen works part-time, creating financial pressure from the extended time off work. He has a strong cultural connection to the land and the forestry community in Southland; his identity is closely tied to outdoor manual work. With 28 years of forestry experience and limited formal qualifications outside trade certifications, transitioning to a different industry would be a significant adjustment. At 52, Owen is openly considering whether forestry remains realistic given his current knee restrictions. He reports some low mood, attributed to inactivity and a sense of lost identity, and is not currently engaged with psychological support but is open to it. He has a supportive whānau and forestry community network.
6a. Pre-Injury Work Role
Please complete this section if the objective includes regaining fitness for the pre-injury role
Has an assessment of the Client's pre-injury work role been completed previously?
[ ] Yes — SAW or WSA Report Date:
[x] No
Please complete the pre-injury role assessment below
Pre-injury role title
Forestry contractor and chainsaw operator (self-employed under contract to Southern Forestry Operations).
Pre-injury role normal working hours/days
50 to 55 hours per week, 5 to 6 days, typically 6:30am to 4:30pm, with seasonal variation.
Pre-injury role work tasks
Felling mature plantation trees with chainsaw; limbing and bucking logs; setting chokers for logging; operating ground-based felling equipment; minor machinery maintenance; on-site safety supervision; assisting hauler operations on steep terrain; truck loading; daily PPE checks and tool sharpening.
Pre-injury role physical and cognitive demands
Sustained standing, walking, and climbing on uneven and steep terrain; carrying a chainsaw (8 to 10 kg) for extended periods; frequent kneeling, squatting, and crouching; repetitive lifting of logs and tools up to 30 kg; sustained shoulder and trunk endurance; high-vigilance terrain hazard assessment; rapid decision-making in a high-risk environment; precise hand-eye coordination for chainsaw operation; weather tolerance; team communication on noisy sites.
What rehabilitation does the Client require to regain fitness for this role?
Owen requires a structured, work-specific functional rehabilitation programme focused on rebuilding lower limb strength (particularly quadriceps), single-leg control, balance and proprioception on uneven surfaces, and progressive load tolerance for kneeling, squatting, and load carriage. A graded re-introduction to terrain-based functional tasks is essential to confirm whether the right knee can sustain the demands of full forestry work. Concurrent attention to mood and identity-related concerns is recommended. Estimated programme duration is 16 weeks, with a 12 week functional re-evaluation to determine continuation of the pre-injury pathway or transition to vocational independence.
6b. Work readiness for Vocational independence (VI)
Please complete this section if the objective includes achieving work readiness for VI
Has an IOA/IMA been completed?
[ ] Yes
[x] No
If no, is an IOA/IMA recommended?
i.e. the outcome is unlikely to be regaining fitness for the pre-injury role
[x] Yes
[ ] No
Other non-specific rehabilitation required, or barriers to be addressed, to achieve work readiness:
Cardiovascular reconditioning following 8 months of significantly reduced activity
Psychological support for adjustment, identity, and mood concerns
Career counselling and skills mapping in the event the VI pathway becomes necessary
Computer and basic administrative skill development if a transition to office-based or supervisory roles within the forestry sector is being considered
Exploration of transferable skills (site safety, training, mentoring of newer operators) that could open lower-physical-demand roles within forestry
7. Activities to help achieve the overall objective
List of proposed activities to meet the rehabilitation requirements as listed in 6a and/or 6bProposed completion date of the activityLower limb strengthening and proprioception programme (physiotherapy 2/week)14/08/2026Functional terrain progression programme (graded exposure to slopes, uneven ground, kneeling tasks)28/08/2026Work specific functional rehabilitation including chainsaw simulation and load carriage28/08/2026Cardiovascular reconditioning (cycling, swimming, walking programme)30/06/2026Psychological support referral and initial engagement21/06/2026Career counselling and skills mapping session (contingency for VI pathway)30/06/2026IOA/IMA initiation as a parallel contingency30/06/202612 week functional re-evaluation and pathway decision04/08/2026
Is a Work Specific Functional Rehabilitation required as part of this service?
[x] Yes
[ ] No
If yes, provide the reason for why programme is required:
Owen's pre-injury role as a forestry contractor involves high-risk, terrain-specific physical demands (sustained kneeling, squatting, load carriage on slopes, and chainsaw operation) that cannot be adequately replicated or assessed within standard gym-based rehabilitation. A Work Specific Functional Rehabilitation programme is required to safely progress and objectively assess his readiness to return to forestry work, and to confirm the appropriate pathway at the 12 week functional re-evaluation.
9. 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: Aroha Tane
Provider discipline: Vocational Rehabilitation Consultant (Occupational Therapist)
Signature:
Date: 22/05/2026
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
Section 6, KOOS sport and recreation subscale: stated verbally as "thirty-eight out of one hundred"; verify 38/100 matches Owen's documented KOOS questionnaire result rather than a clinical estimate.
Section 6a, Pre-injury normal working hours: stated as "around 50 to 55 hours per week"; confirm the exact contracted hours with Owen's forestry contracting agreement before submission.
**ACC7431**
**Back to Work – Initial and Progress Report**
"A Back to Work (BTW) provider completes this form to update ACC on a client's progress towards their return-to-work rehabilitation."
"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. Report stage**
(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.)
[ ] Initial — _"Complete sections 1 to 7 and sign section 9"_ (Mark with '[x]' if this is an initial report. Leave '[ ]' if not explicitly mentioned. These 2 options are mutually exclusive — only one must be marked with '[x]'. Do not omit any options.)
[ ] Progress (number): [progress report number in the format X of Y, where X is the current report number and Y is the total] (Mark with '[x]' if this is a progress report. Leave '[ ]' if not explicitly mentioned. These 2 options are mutually exclusive — only one must be marked with '[x]'. Do not omit any options.) — _"Additionally complete section 8 and sign section 9. Only the current progress report is required."_
**Date of this report:** [date of this report] (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. 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)
**3. 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)
**4. Overall objectives**
_"What is the overall objective specified in the referral? You may tick more than one"_
(Mark with '[x]' based on information explicitly mentioned in the transcript, contextual notes, or clinical note. You may mark more than one of the following options. Do not omit any options.)
[ ] Regain fitness for Pre-injury Work Role (Mark with '[x]' if regaining fitness for the pre-injury work role is specified as an objective. Leave '[ ]' if not explicitly mentioned. Do not omit any options. If marked '[x]', section 6a should also be completed.)
_"Please also complete section 6a"_
[ ] Work readiness for Vocational independence (VI) (Mark with '[x]' if work readiness for vocational independence is specified as an objective. Leave '[ ]' if not explicitly mentioned. Do not omit any options. If marked '[x]', section 6b should also be completed.)
_"Please also complete section 6b"_
[ ] Obtain employment (Mark with '[x]' if obtaining employment is specified as an objective. Leave '[ ]' if not explicitly mentioned. Do not omit any options.)
[ ] Other (Mark with '[x]' if another objective not listed above is specified. Leave '[ ]' if not explicitly mentioned. Do not omit any options.)
Comment:
[comment on overall objectives] (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. Relevant contacts involved in the client's rehabilitation**
[relevant contacts involved in the client's rehabilitation] (Format each contact as a new row in a five-column markdown table. The columns are: Name of person, Role, Email, Phone, and Date of contact. Print all dates in DD/MM/YYYY format. Use a hyphen "-" for any fields that are not mentioned. Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
**6. Initial assessment**
**Date of initial assessment:** [date of initial assessment] (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)
**Outcome target date on referral:** [outcome target date on referral] (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)
**Outcome target date following assessment:** [outcome target date following assessment] (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)
If applicable, the reason for the new target date:
[reason for the new outcome target date] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
**<u>Assessment summary of the Client</u>**
**Brief injury history**
[brief history of the client's injury] (Summarise the client's injury history as discussed. Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
**Functional presentation / limitations**
[client's functional presentation and limitations] (Describe the client's current functional presentation and any limitations identified. Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
**Medical certificate status**
[client's current medical certificate status] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
**Biopsychosocial, cultural, and other factors (including barriers)**
[biopsychosocial, cultural, and other factors including barriers to recovery] (Describe all relevant biopsychosocial, cultural, and other factors including any barriers to recovery identified. Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
**6a. Pre-Injury Work Role**
(Only include this section if Regain fitness for Pre-injury Work Role is marked '[x]' in section 4. If Regain fitness for Pre-injury Work Role is not marked '[x]', omit this section entirely.)
_"Please complete this section if the objective includes regaining fitness for the pre-injury role"_
**Has an assessment of the Client's pre-injury work role been completed previously?**
(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 — SAW or WSA Report Date: [stay at work or workplace assessment report date] (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) (Mark with '[x]' if an assessment of the client's pre-injury work role has been completed previously. 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 an assessment of the client's pre-injury work role has not been completed previously. Leave '[ ]' if not explicitly mentioned. These 2 options are mutually exclusive — only one must be marked with '[x]'. Do not omit any options.)
_"Please complete the pre-injury role assessment below"_
(Only include the following pre-injury role assessment fields if the previous assessment question is marked '[x]' for No. If marked '[x]' for Yes, omit the fields below but retain the sub-section headings and leave blank.)
**Pre-injury role title**
[client's pre-injury role title] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
**Pre-injury role normal working hours/days**
[client's pre-injury role normal working hours and days] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
**Pre-injury role work tasks**
[client's pre-injury role work tasks] (Describe the work tasks associated with the client's pre-injury role. Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
**Pre-injury role physical and cognitive demands**
[physical and cognitive demands of the client's pre-injury role] (Describe the physical and cognitive demands of the role. Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
What rehabilitation does the Client require to regain fitness for this role?
[rehabilitation required for the client to regain fitness for the pre-injury role] (Describe the rehabilitation the client requires to regain fitness for the pre-injury work role. Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
**6b. Work readiness for Vocational independence (VI)**
(Only include this section if Work readiness for Vocational independence is marked '[x]' in section 4. If Work readiness for Vocational independence is not marked '[x]', omit placeholders but retain all section headings, subheadings, and lead-ins, and leave blank.)
_"Please complete this section if the objective includes achieving work readiness for VI"_
Has an IOA/IMA been completed?
(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 an initial occupational assessment or initial medical assessment has been completed. 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 an initial occupational assessment or initial medical assessment has not been completed. Leave '[ ]' if not explicitly mentioned. These 2 options are mutually exclusive — only one must be marked with '[x]'. Do not omit any options.)
If no, is an IOA/IMA recommended?
_"i.e. the outcome is unlikely to be regaining fitness for the pre-injury role"_
(Only include the following question if the initial occupational assessment or initial medical assessment completion question above is marked '[x]' for No. If marked '[x]' for Yes, omit this question entirely.)
(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 an initial occupational assessment or initial medical assessment is recommended. 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 an initial occupational assessment or initial medical assessment is not recommended. Leave '[ ]' if not explicitly mentioned. These 2 options are mutually exclusive — only one must be marked with '[x]'. Do not omit any options.)
"If completed, list the work types assessed as medically sustainable, or likely to be, from the IMA and the vocational rehabilitation needs identified."
(Only include the following table if the initial occupational assessment or initial medical assessment completion question above is marked '[x]' for Yes.)
[work types assessed as medically sustainable and vocational rehabilitation needs] (Format each work type as a new row in a three-column markdown table. The columns are: Work Type, Vocational rehabilitation needs (from initial occupational assessment or initial medical assessment) specific to each work type, and Agreed to be supported by ACC. For the Agreed to be supported by ACC column, print one of the following: "Yes", "No / N/A", or "To be advised". Use a hyphen "-" for any fields that are not mentioned. 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 non-specific rehabilitation required, or barriers to be addressed, to achieve work readiness:
[other non-specific rehabilitation required or barriers to be addressed to achieve work readiness] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
**7. Activities to help achieve the overall objective**
[proposed activities to meet the rehabilitation requirements as listed in sections 6a and/or 6b] (Format each proposed activity as a new row in a two-column markdown table. The columns are: List of proposed activities to meet the rehabilitation requirements as listed in 6a and/or 6b, and Proposed completion date of the activity. Print all dates in DD/MM/YYYY format. Use a hyphen "-" for any fields that are not mentioned. Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
Is a Work Specific Functional Rehabilitation required as part of this service?
(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 a work specific functional rehabilitation programme is required as part of this service. 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 a work specific functional rehabilitation programme is not required as part of this service. 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, provide the reason for why programme is required:
[reason why the work specific functional rehabilitation programme is required] (Only include if the work specific functional rehabilitation question above is marked '[x]' for Yes. If marked '[x]' for No, omit this placeholder but retain the 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)
**8. Progress report**
(Only include this section if Progress is marked '[x]' in section 1. If Initial is marked '[x]' in section 1, omit this section entirely.)
"Please provide a progress update to ACC and/or make a request for further services."
**Date of report:** [date of progress report] (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)
**Progress report number:** [progress report number in the format X of Y, where X is the current report number and Y is the total] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
Has a functional programme been provided?
(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 a functional programme has been provided. 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 a functional programme has not been provided. 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, complete the table below"
(Only include the following table if the functional programme question above is marked '[x]' for Yes. If marked '[x]' for No, omit the table entirely.)
[functional programme details] (Format each work specific task as a new row in a three-column markdown table. The columns are: Work Specific Task / Requirement, Client's current ability to undertake the task, and Specific functional activities to be undertaken. Use a hyphen "-" for any fields that are not mentioned. Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
**Progress since the previous report**
_"Please state progress towards overall objectives, whether the timeframes set in the initial report are still going to be met. If not, what are the new timeframes and why have these changed."_
[progress since the previous report including whether timeframes are being met and any changes to timeframes] (Describe progress towards the overall objectives, whether the timeframes set in the initial report are still going to be met, and if not, detail the new timeframes and reasons for the changes. Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
**Has a work trial been obtained for the Client?**
(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 a work trial has been obtained for the client. Leave '[ ]' if not explicitly mentioned. These 3 options are mutually exclusive — only one must be marked with '[x]'. Do not omit any options.)
[ ] No (Mark with '[x]' if a work trial has not been obtained for the client. Leave '[ ]' if not explicitly mentioned. These 3 options are mutually exclusive — only one must be marked with '[x]'. Do not omit any options.)
[ ] Not Required (Mark with '[x]' if a work trial is not required for the client. Leave '[ ]' if not explicitly mentioned. These 3 options are mutually exclusive — only one must be marked with '[x]'. Do not omit any options.)
"If yes, please provide details:"
(Only include the following work trial details table if the work trial question above is marked '[x]' for Yes. If marked '[x]' for No or Not Required, omit the table entirely.)
[work trial details] (Format each work trial period as a new row in a five-column markdown table. The columns are: Dates, Days to work, Hours per day, Work tasks, and Details of restrictions and rehabilitation. Print all dates in DD/MM/YYYY format. Use a hyphen "-" for any fields that are not mentioned. Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
Has the client's medical practitioner approved the work trial or return-to-work plan?
"(If yes, please attach a copy to the report)"
(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's medical practitioner has approved the work trial or return-to-work plan. 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's medical practitioner has not approved the work trial or return-to-work plan. Leave '[ ]' if not explicitly mentioned. These 2 options are mutually exclusive — only one must be marked with '[x]'. Do not omit any options.)
If no, please state why:
[reason why the client's medical practitioner has not approved the work trial or return-to-work plan] (Only include if the medical practitioner approval question above is marked '[x]' for No. If marked '[x]' for Yes, omit this placeholder but retain the 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)
What further service level is being requested?
(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.)
[ ] No further service required (Mark with '[x]' if no further service is required. Leave '[ ]' if not explicitly mentioned. These 7 options are mutually exclusive — only one must be marked with '[x]'. Do not omit any options.)
[ ] BTW 2 — "no prior approval required" (Mark with '[x]' if Back to Work level 2 is being requested. Leave '[ ]' if not explicitly mentioned. These 7 options are mutually exclusive — only one must be marked with '[x]'. Do not omit any options.)
[ ] BTW 3 (VRB13) (Mark with '[x]' if Back to Work level 3 is being requested. Leave '[ ]' if not explicitly mentioned. These 7 options are mutually exclusive — only one must be marked with '[x]'. Do not omit any options.)
[ ] BTW Exceptional (VRB14) (Mark with '[x]' if Back to Work Exceptional is being requested. Leave '[ ]' if not explicitly mentioned. These 7 options are mutually exclusive — only one must be marked with '[x]'. Do not omit any options.)
[ ] BTW Initial Functional Rehab (VRB24) (Mark with '[x]' if Back to Work Initial Functional Rehabilitation is being requested. Leave '[ ]' if not explicitly mentioned. These 7 options are mutually exclusive — only one must be marked with '[x]'. Do not omit any options.)
[ ] BTW Follow up Functional Rehab (VRB25) (Mark with '[x]' if Back to Work Follow up Functional Rehabilitation is being requested. Leave '[ ]' if not explicitly mentioned. These 7 options are mutually exclusive — only one must be marked with '[x]'. Do not omit any options.)
[ ] Other (Mark with '[x]' if another service level not listed above is being requested. Leave '[ ]' if not explicitly mentioned. These 7 options are mutually exclusive — only one must be marked with '[x]'. Do not omit any options.)
**Please provide a detailed reason for requesting additional services:**
[detailed reason for requesting additional services] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
[additional activities and their proposed completion dates and expected outcomes] (Format each additional activity as a new row in a three-column markdown table. The columns are: List of additional activities, Proposed completion date of the activity, and Detail the outcome of the activity and how this will achieve the overall objective. Print all dates in DD/MM/YYYY format. Use a hyphen "-" for any fields that are not mentioned. 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 other comments:**
[any other 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)
**9. 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.)
