Compensation for Occupational Injuries and Diseases Act, 1993 (Act No. 130 of 1993)
Scale of Fees
Annual Increase in Medical Tariffs for Medical Service Providers - 2018
Physiotherapy Services, Occupational Therapy Services and Chiropractor Services
Rehabilitation Progress Report
Claim Number: ................................
REHABILITATION PROGRESS REPORT
COMPENSATION FOR OCCUPATIONAL INJURIES AND DISEASE ACT
Names and Surname of Employee
Identity Number Address
Name of Employer
Date of Accident
|1.||Date of first treatment Provider who provided first treatment|
|2.||Initial clinical presentation and functional status|
|3.||Name of referring medical practitioner Date of referral|
|4.||Describe patient's current symptoms and functional status|
|5.||Are there any complicating factors that may prolong rehabilitation or delay recovery (specify)?|
|6.||Overall goal of treatment:|
7. Number of sessions already delivered Progress achieved
8. Number of sessions required Treatment plan for proposed treatment sessions
9. From what date has the employee been fit for his/her normal work?
|10.||Is the employee fully rehabilitated/has the employee obtained the highest level of function?|
|11.||If so, describe in detail any present permanent anatomical defect and/or impairment of function as a result of the accident (R.O.M, if any must be indicated in degrees at each specific joint)|
I certify that I have by examination, satisfied myself that the injury (ies) are as a result of the accident.
Signature of rehabilitation service provider
Name (Printed) Date (Important)
N.B. Rehabilitation progress reports must be submitted on a monthly basis and attached to the submitted accounts.
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