Form 132A Application for assessment
of permanent impairment
This is an approved form under section 132A of the Workers’ Compensation and Rehabilitation Act 2003
Version 1
Important instructions and privacy statement
 This form is to be completed where a worker requests a permanent impairment assessment
to determine if their injury/ies has resulted in a degree of permanent impairment but has not
already made an application for compensation for that injury/ies.
 This form is not to be completed if the worker has already made an application for
compensation of their injury/ies under section 132 of the Workers’ Compensation and
Rehabilitation Act 2003.
 To be eligible to make this application you must have been a worker at the time of the event
that resulted in the injury relevant to this application.
 Your application needs to be accompanied by a Workers’ Compensation Medical Certificate
in the approved form.
 Your application needs to be accompanied by any other evidence or particulars prescribed
under regulation 85A. This includes but is not limited to incident/accident reports or other
material verifying the event and medical evidence such as medical certificates, radiological
reports or other medical reports. If the information required is not provided, the administration
of your application may be delayed or it may not be possible to further progress the
application.
 The information collected by this form and throughout the course of your application is
collected in accordance with the Workers’ Compensation and Rehabilitation Act 2003 and
Workers’ Compensation and Rehabilitation Regulation 2003.
 The information may be disclosed to the Workers’ Compensation Regulator, medical and
allied health providers and other insurers as needed to assess your application.
Please note: If there is insufficient space on the form, you may attach separate sheets. If you
attach separate sheets, please ensure they are signed and dated by you as the applicant.
Worker’s details
Title:
Given names:
Gender
Date of birth:
Surname:
 Female
/
/
 Male
Has the worker ever been known by any other name/s?
Yes
 (if yes, please provide details below)
Title:
Given names:
Residential
address:
Postal address:
Telephone:
Email address:
No

Surname:
(If same as residential, please write ‘as above’.)
Mobile number:
This form was approved by the Workers’ Compensation Regulator on 21 January 2014 pursuant to section 586 of the Workers’
Compensation and Rehabilitation Act 2003.
Form 132A v1
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Form 132A Application for assessment
of permanent impairment
This is an approved form under section 132A of the Workers’ Compensation and Rehabilitation Act 2003
Version 1
Workers’ employment details at date of event causing injury
Usual occupation:
Full time or Part time
Nature of employment at time of event (if different to usual occupation)
Details of employer at the time of the event causing injury
Employer trading
name
Business address:
(street address)
Details of other employer at the time of the event causing injury (including selfemployment)
Employer’s trading
name:
Business street
address:
Work telephone:
Email address
Mobile:
Date of the event resulting in the injury
Date of event:
Time of event:
Date of first consultation with medical practitioner about injury
If the event occurred over a period of time:
Date the event period began:
Date the event period ended:
Date the symptoms began:
Date of first consultation with
medical practitioner
Exact location where event occurred (e.g. driveway, State Law Building, 50 Ann St Brisbane)
Place:
Street address:
Complete and detailed description of the event resulting in the injury
If more space is required, please attach event description on separate sheet of paper.
This form was approved by the Workers’ Compensation Regulator on 21 January 2014 pursuant to section 586 of the Workers’
Compensation and Rehabilitation Act 2003.
Form 132A Application for assessment
of permanent impairment
This is an approved form under section 132A of the Workers’ Compensation and Rehabilitation Act 2003
Version 1
Details of all injuries alleged to have been sustained because of the event
Part of body injured (e.g. right index
finger, lower back)
Nature of injury/ies (e.g. strain, fracture, crush, burn)
Details of all doctors, hospitals, rehabilitation and any other service providers from
whom the worker received treatment for the injury arising from the event
Name of doctor/hospital/provider
Address
Details of employer representative to whom injury was reported
Name:
Position:
Business
address:
Telephone:
Email address:
Mobile:
Date reported
Witnesses to the event causing injury
Where there any witnesses to the event?
Yes
 (if yes, please provide their details below)
No

Witness 1
Title:
Given names:
Address:
Telephone:
Relationship if
any to worker
Surname
Mobile
This form was approved by the Workers’ Compensation Regulator on 21 January 2014 pursuant to section 586 of the Workers’
Compensation and Rehabilitation Act 2003.
Form 132A Application for assessment
of permanent impairment
This is an approved form under section 132A of the Workers’ Compensation and Rehabilitation Act 2003
Version 1
Witness 2
Title:
Given names:
Address:
Telephone:
Relationship if
any to worker
Surname
Mobile
Has the worker sustained any other personal injury/ies, illness/es, impairment/s or
condition/s of a medical, psychiatric or psychological nature either before or after the
event that may affect the degree of permanent impairment resulting from the injury to
which this application relates?
Yes
Injury, illness,
impairment
 (if yes, please complete table below)
Date of injury
Name of treating
doctor/hospital
No

Address of treating doctor/hospital
Has the worker ever made a claim, either before or since the event, for damages,
compensation or benefits as a result of any other personal injury/ies, illness/es,
impairment/s or condition/s of a medical, psychiatric or psychological nature?
Yes
 (if yes, please complete tables below)
Claim number
Injury, illness or
impairment
Name of Insurer
Address of Insurer
Name of employer
against whom claim
was made
Address of employer
No

Date of injury
Claim number
Date of injury
Injury, illness or
impairment
Name of Insurer
Address of Insurer
Name of employer
against whom claim
was made
Address of employer
NB: If more claims have been made, please attach details to this form
This form was approved by the Workers’ Compensation Regulator on 21 January 2014 pursuant to section 586 of the Workers’
Compensation and Rehabilitation Act 2003.
Form 132A Application for assessment
of permanent impairment
This is an approved form under section 132A of the Workers’ Compensation and Rehabilitation Act 2003
Version 1
Worker’s Statement
I declare that I wish to have the injury/ies listed on this form assessed for a degree of
permanent impairment pursuant to section 132A of the Workers’ Compensation and
Rehabilitation Act 2003.
I acknowledge that it is an offence under the Workers’ Compensation and Rehabilitation Act
2003 to make a statement that is false or misleading. The information I have provided is true
and not misleading.
I agree to advise the insurer if my circumstances change or if I become aware of any matter that
would make the above information false or misleading.
I authorise any hospital, ambulance service of the state or another state, a doctor, provider of
treatment or rehabilitation services or person qualified to assess cognitive, functional or
vocational capacity or an employer, or previous employer or insurers that carry on the business
of providing workers’ compensation insurance, compulsory third party insurance, personal
accident or illness insurance, insurance against the loss of income through disability,
superannuation funds or any other type of insurance or a department, agency or instrumentality
of the Commonwealth or the State or a solicitor, other than where giving information would
breach legal professional privilege.
Applicant’s
full name:
Applicant’s
signature:
Date:
/
/
Date:
/
/
If applicant is unable to sign this form:
Agent’s full
name:
Agent’s
signature:
This form was approved by the Workers’ Compensation Regulator on 21 January 2014 pursuant to section 586 of the Workers’
Compensation and Rehabilitation Act 2003.