Victorian Numbered Regulations

WRONGS (PART VBA CLAIMS) REGULATIONS 2005 (SR NO 27 OF 2005) - SCHEDULE

SCHEDULE

FORM 1

Form 1

Regulation 3

CERTIFICATE OF ASSESSMENT OF DEGREE OF IMPAIRMENT ARISING FROM STABILISED INJURY

Wrongs Act 1958

Section 28LN

DETAILS OF MEDICAL PRACTITIONER

Name:

Qualification:

Address:

Telephone:

Fax:

CERTIFICATION

I certify that on: (date) I examined: ( insert name of person seeking the assessment )

of ( address of person seeking the assessment ):

and I am satisfied/I am not satisfied ( delete whichever inapplicable ) that: ( tick appropriate box/boxes )

o     the degree of impairment resulting from this person's injury is more than 5%.

Brief description of injury assessed:

o     the degree of impairment resulting from this person's psychiatric injury is more than 10%.

Brief description of psychiatric injury assessed:

SIGNED:     DATED:

Please note:

This certificate must be provided by a medical practitioner who is an "approved medical practitioner" within the meaning of section 28LB of the Wrongs Act 1958 .
Form 1

This certificate must not state the specific degree of impairment.

Impairment means permanent impairment.

__________________

FORM 2

Regulation 4

CERTIFICATE OF ASSESSMENT OF DEGREE OF IMPAIRMENT WHERE INJURY HAS NOT STABILISED

Form 2

Wrongs Act 1958

Section 28LNA

DETAILS OF MEDICAL PRACTITIONER

Name:

Qualification:

Address:

Telephone:

Fax:

CERTIFICATION

I certify that on: (insert date) I first examined ( insert name of person seeking the assessment ):

of ( address of person seeking the assessment ):

in relation to: ( tick appropriate box/boxes )

o     an injury.

Brief description of injury assessed:

I certify that I have conducted a subsequent examination today in relation to the same injury and I am unable to determine the degree of impairment. However, I am satisfied that the degree of impairment resulting from this injury will be more than 5% once the injury has stabilised.

o     a psychiatric injury.

Brief description of psychiatric injury assessed:

I certify that I have conducted a subsequent examination today in relation to the same psychiatric injury and I am unable to determine the degree of impairment. However, I am satisfied that the degree of impairment resulting from this psychiatric injury will be more than 10% once the injury has stabilised.

SIGNED:     DATED:

Please note:

This certificate must be provided by a medical practitioner who is an "approved medical practitioner" within the meaning of section 28LB of the Wrongs Act 1958 .
Form 2

The date of the first examination of the person seeking an assessment must be at least six months before the date of this assessment.

Impairment means permanent impairment.

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