Acts Online
GT Shield

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

Chiropractor Services

Rehabilitation Progress Report


Claim Number: ................................







Names and Surname of Employee                                                                                                                              

Identity Number                                                   Address                                                                                            

                                                                                                                Postal Code                                                          


Name of Employer                                                                                                                                                              


                                                                                                                Postal Code                                                          


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)                                                            


Practice number                                                                    


N.B.  Rehabilitation progress reports must be submitted on a monthly basis and attached to the submitted accounts.