ACC7980 Back to Work completion report

**ACC7980** **Back to Work – Completion Report** "A Back to Work (BTW) provider completes and submits this form to ACC on the date the client is discharged from the BTW programme." "Submit this form to the ACC contact person or claims@acc.co.nz" **1. Client details** **Client name:** John Smith **Claim number:** ACC000-TESTCLAIM-06 **Date of injury:** 01/04/2026 **2. Supplier Contact details** **Supplier company name:** Stark Rehabilitation Industries **Service Delivery Company name:** Stark Rehabilitation Industries **Lead Provider name:** Tony Stark **Lead Provider phone:** 03 555 0512 **Lead Provider email address:** tony.stark@starkrehab.co.nz **3. Completion Outcome** | Outcome | Outcome Achieved | |---|---| | Rehabilitation complete for the pre-injury role and this role is now considered sustainable | [x] | | The client is considered work ready for vocational independence | [ ] | | Obtained employment | [ ] | | No outcome achieved | [ ] | Pre-Injury role: Panel Beater **4. Rehabilitation** The client completed a progressive shoulder strengthening programme through to 15/06/2026, followed by a graded return-to-work trial involving light panel preparation duties from 01/10/2026, which was extended on 05/08/2026 to include limited overhead tasks. Following this extension, the client progressed to full overhead panel-beating duties without restriction, with the programme completed on 20/11/2026. No previously recommended vocational training or rehabilitation was left incomplete. Does this client require any more assistance from ACC? [ ] Yes [x] No Any additional comments: The client's employer has confirmed his full return to pre-injury duties, and the client reported feeling confident performing his usual panel-beating tasks without restriction. **5. Provider declaration and signature** "I declare the information provided by me on this form is, to the best of my knowledge, accurate and complete." **Provider name:** Tony Stark **Provider discipline:** Physiotherapist **Signature:** **Date:** 20/11/2026 "When we collect, use and store information, we comply with the Privacy Act 2020 and the Health Information Privacy Code 2020. For further details see ACC's privacy policy, available at [www.acc.co.nz](https://www.acc.co.nz). We use the information collected on this form to fulfil the requirements of the Accident Compensation Act 2001." **Items for Clinician Review** [ ] Section 4 – Rehabilitation: the transition from the extended work trial to "full overhead panel-beating duties without restriction" was inferred as occurring between 05/08/2026 and the completion date of 20/11/2026, without an exact date the restriction was lifted; confirm the precise date if available. [ ] Section 3 – Completion Outcome: only the pre-injury role outcome was marked; confirm this is the sole outcome achieved and that vocational independence / obtained employment do not also apply in combination.