Form · Personal Injury & Compensation

WorkSafe worker's injury claim form: completion guide

Guide to the WorkSafe worker's injury claim form, in myWorkSafe or as a PDF, including the certificate of capacity, the signed medical authority and declaration, and mental-injury rules from 31 March 2024.

Kind: Form. A form to complete, or a guide to completing an official one.
Where it applies: Victoria
AI use: Yellow You and the tool draft together, with you directing. You check every statement you rely on.
Law stated as at: 23 October 2026
Status: Maintained. Checked on 23 October 2026 against the official form at worksafe.vic.gov.au and the 3 authorities it cites, for Victoria.
Version: 1
Source: Link to the official form. Licence: © State of Victoria. Link only: download the current form from the official page each time; do not copy or adapt it.

Where this comes from

The official form is published by worksafe.vic.gov.au; this page is a completion guide. Last checked on 2026-10-23.

When to use it

Use when a worker is claiming weekly payments or medical and like expenses for a work injury in Victoria. The worker completes the official form and gives it to the employer, unless direct lodgement applies. For a death, use the work-related death claim form.

Used for these tasks

Each task page says how far AI may help with the task and what the lawyer must review.

How AI may be used

The tool may list the documents the worker still needs and diary the certificate and deeming dates the lawyer confirms; the worker completes and signs the official form.

AI may

List injuries already named on the file so the lawyer can check each one is on the certificate of capacity
Note whether the claim includes a mental injury and whether the injury date is before or after 31 March 2024
Diary the date a valid certificate reaches the agent, because the claims manual ties the 28-day deeming clock to that date

AI must not

Must not write the worker's answers, or sign the authority to release medical information and declaration
Must not decide that a mental injury is compensable, or that management action was unreasonable
Must not treat help filling in the form as lodgement
Must not state a time limit for lodging the claim. The pages opened do not give one

The lawyer checks

Questions 1 to 6 of Part A are the worker's. The employer completes question 7 and Part B, unless direct lodgement applies
A PDF or paper form is signed at the authority and declaration. On myWorkSafe the claims manual treats the form as electronically signed on submission
Every injury on the form is on the certificate of capacity. For weekly payments the certificate meets the claims manual's section 25 points
For a mental injury on or after 31 March 2024, the certificate uses the latest DSM and states significant behavioural, cognitive or psychological dysfunction
Provisional payments for a mental injury: the agent usually answers within 5 business days, and if the claim is rejected may cover reasonable treatment for up to 13 weeks
Health information stays in a firm-controlled tool. Check ASCR r 9, APP 11, and whether any disclosure would be a notifiable breach under the Privacy Act 1988 (Cth).

Method: how the Green, Yellow and Red levels are decided. This is guidance for planning, not legal advice.

Authorities

Official form

Open the official form. Always use the current version from the issuer. Licence: © State of Victoria. Link only: download the current form from the official page each time; do not copy or adapt it..

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