Document ID: chunk:federal_register_of_legislation:F2019L01192:body:0:p3
Version: federal_register_of_legislation:F2019L01192
Segment Type: other
Provision Reference: 
Character Range: 6014–10227

company:                                                                                                    State:         Postcode:
Name and position of person/s authorised to sign this application on behalf of the organisation:
Name:                                                                                                             Title:
Name:                                                                                                             Title:

Application contact person
Name:                                                                                                                          Title:
Phone:                                                                                                                         Mobile:
Email:

Approval in other workers' compensation jurisdictions
Please list the workers' compensation jurisdictions in which you are approved to provide workplace rehabilitation services.

Previous applications
Have you ever been refused approval, or had your approval withdrawn, to provide workplace rehabilitation services by Comcare or any other Australian workers compensation authority?
                                                                                                                                                                                       o Yes  o No
If you answered yes, please provide details of the reasons for refusal or withdrawal of approval

Please also detail any steps you have taken since being refused approval to address the identified issue or issues.

Conflicts of interest
                                                                                                                                                                                       o Yes  o No
Do you have, or are you likely to have any actual or perceived conflict of interest between your role as an approved program provider and any other interest?

If 'yes', what are the details of this conflict?
What steps will you take to manage this conflict?

Professional misconduct or criminal proceedings
Have any professional misconduct, discipline, criminal or civil proceedings ever been commenced against you, or anyone engaged or caused to be engaged by you, in relation to your work as a rehabilitation program provider?

If so, please provide details of any charges or complaints and the results of any proceedings.

Please also provide reasons why Comcare should not reject your application.

Insurance currency
Please provide the following documentation and details

      * Professional Indemnity Insurance
      * Public Liability Insurance
      * Workers Compensation Insurance
(For each State or Territory of operation as applicable, if you have an exemption please indicate for which State/Territory)

PART B – CONFORMING TO THE CRITERIA AND ANY CONDITIONS OF APPROVAL

Note. This part refers to a person being 'relevantly qualified'. This is an important concept that is defined in subsection 6(4) of the Criteria. Please ensure that you understand this concept before completing this section.

Person in senior management to be relevantly qualified
If you are approved to provide rehabilitation services, you will be required to have at least one person as part of your senior management who is:
      * 'relevantly qualified', and
      * has at least five years' experience providing workplace rehabilitation services as a 'relevantly qualified' person.
Please provide the details in relation to that person:
Name:                                                                                                                                               Title:
Qualifications demonstrating that the person is 'relevantly qualified':
      * Relevant qualifications
      * Professional registration number/professional membership number/accreditation number (as applicable)
      * Comcare identification number (if applicable)
Details of that person's experience providing workplace rehabilitation services as a 'relevantly qualified person':
      * Please attach a resume

Relevantly qualified

Please provide the following details for any person engaged, or who would be engaged,