ACC7431 Back to Work - initial and progress report

**ACC7431** **Back to Work – Initial and Progress Report** "A Back to Work (BTW) provider completes this form to update ACC on a client's progress towards their return-to-work rehabilitation." "Submit this form to the ACC contact person or claims@acc.co.nz" **1. Report stage** [ ] Initial — _"Complete sections 1 to 7 and sign section 9"_ [x] Progress (number): 2 of 3 — _"Additionally complete section 8 and sign section 9. Only the current progress report is required."_ **Date of this report:** 20/10/2026 **2. Client details** **Client name:** John Smith **Claim number:** ACC000-TESTCLAIM-06 **Date of injury:** 01/04/2026 **3. 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 **4. Overall objectives** [x] Regain fitness for Pre-injury Work Role _"Please also complete section 6a"_ [ ] Work readiness for Vocational independence (VI) [ ] Obtain employment [ ] Other Comment: The client's goal is to return to full duties in his pre-injury role as a panel beater, which involves repetitive overhead work. **5. Relevant contacts involved in the client's rehabilitation** | Name of person | Role | Email | Phone | Date of contact | | --- | --- | --- | --- | --- | | Dr John Watson | GP | - | - | 15/04/2026 | | Jane Doe | ACC Case Manager | jane.doe@acc.co.nz | 04 555 0123 | 15/04/2026 | **6. Initial assessment** **Date of initial assessment:** 15/04/2026 **Outcome target date on referral:** 15/07/2026 **Outcome target date following assessment:** 15/08/2026 If applicable, the reason for the new target date: An additional month was added following assessment to allow for a structured shoulder strengthening programme before progressing to overhead work tasks. **Assessment summary of the Client** **Brief injury history** The client sustained a right shoulder rotator cuff strain following a fall at work on 01/04/2026 while lifting a panel. **Functional presentation / limitations** The client presents with reduced overhead reach and reduced lifting capacity on the right side, limiting his ability to perform panel-beating tasks that require sustained overhead positioning. **Medical certificate status** The client currently holds a partial capacity certificate, restricted to light duties with no overhead work. **Biopsychosocial, cultural, and other factors (including barriers)** The client is motivated to return to his usual role and has a supportive employer willing to accommodate a graded return. He reported some frustration at the pace of his recovery relative to his own expectations. **6a. Pre-Injury Work Role** **Has an assessment of the Client's pre-injury work role been completed previously?** [x] Yes — SAW or WSA Report Date: 15/04/2026 [ ] No **7. Activities to help achieve the overall objective** | List of proposed activities to meet the rehabilitation requirements as listed in 6a and/or 6b | Proposed completion date of the activity | | --- | --- | | Progressive shoulder strengthening programme | 15/06/2026 | | Graded return to overhead work tasks | 15/08/2026 | Is a Work Specific Functional Rehabilitation required as part of this service? [x] Yes [ ] No If yes, provide the reason for why programme is required: The client's role requires repetitive overhead work, so a work-specific functional rehabilitation programme is needed to safely rebuild tolerance for these tasks before full return. **8. Progress report** "Please provide a progress update to ACC and/or make a request for further services." **Date of report:** 20/10/2026 **Progress report number:** 2 of 3 Has a functional programme been provided? [x] Yes [ ] No "If yes, complete the table below" | Work Specific Task / Requirement | Client's current ability to undertake the task | Specific functional activities to be undertaken | | --- | --- | --- | | Overhead panel work | Improving; currently tolerates approximately 30 minutes of intermittent overhead work | Graded overhead reaching and lifting tasks, twice-weekly sessions | **Progress since the previous report** The client has made steady progress with his shoulder strengthening programme and is now tolerating short periods of overhead work. Progress remains on track to meet the outcome target date of 15/08/2026 set following the initial assessment. **Has a work trial been obtained for the Client?** [x] Yes [ ] No [ ] Not Required "If yes, please provide details:" | Dates | Days to work | Hours per day | Work tasks | Details of restrictions and rehabilitation | | --- | --- | --- | --- | --- | | 01/10/2026 to 20/10/2026 | Monday, Wednesday, Friday | 4 | Light panel preparation tasks, no overhead work | No lifting over 5kg; no sustained overhead positioning | Has the client's medical practitioner approved the work trial or return-to-work plan? [x] Yes [ ] No What further service level is being requested? [ ] No further service required [x] BTW 2 — "no prior approval required" [ ] BTW 3 (VRB13) [ ] BTW Exceptional (VRB14) [ ] BTW Initial Functional Rehab (VRB24) [ ] BTW Follow up Functional Rehab (VRB25) [ ] Other **Please provide a detailed reason for requesting additional services:** Continued graded exposure support is needed to progress the client from his current light-duties work trial to full overhead work tasks ahead of the outcome target date. | List of additional activities | Proposed completion date of the activity | Detail the outcome of the activity and how this will achieve the overall objective | | --- | --- | --- | | Extend work trial to include limited overhead tasks | 05/08/2026 | Builds tolerance for the client's core panel-beating duties, supporting full return to pre-injury role by the target date | **Any other comments:** The client's employer remains supportive of the graded return process and has confirmed light duties can continue to be accommodated as needed. **9. 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:** 20/10/2026 "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 6a – Pre-Injury Work Role: "Yes" was marked for a previous WSA/SAW assessment, so the pre-injury role title, hours, tasks, and demands fields were correctly omitted per the form's own conditional logic; confirm this earlier assessment is on file. [ ] Section 8 – Work trial: hours per day (4) and days (Monday/Wednesday/Friday) were stated once without confirmation of any recent changes; verify against the current work trial agreement. [ ] Section 6 – Outcome target date: the one-month extension reason given ("additional shoulder strengthening programme") is a reasonable inference from the assessment summary rather than an explicit quoted rationale; confirm wording against the original assessment note.