**ACC7430**
**Stay at Work – Initial and Progress Report**
"A Stay at Work (SAW) provider completes this form to update ACC on a client's progress towards returning to their pre-injury work."
"Submit this form to the ACC contact person or claims@acc.co.nz"
(All checkbox options throughout this form must always appear in the output. Never omit any checkbox options. If a checkbox option is not explicitly mentioned in the transcript, contextual notes, or clinical note, leave it as '[ ]'. Do not remove or hide any checkbox options under any circumstances.)
**1. Report stage**
(Mark with '[x]' based on information explicitly mentioned in the transcript, contextual notes, or clinical note. Only one of the following options must be marked with '[x]'. Do not mark more than one. Do not omit any options.)
[ ] Initial — _"Complete sections 1 to 7 and sign section 9"_ (Mark with '[x]' if this is an initial report. Leave '[ ]' if not explicitly mentioned. These 2 options are mutually exclusive — only one must be marked with '[x]'. Do not omit any options.)
[ ] Progress (number): [progress report number in the format X of Y, where X is the current report number and Y is the total] — _"Additionally complete section 8 and sign section 9. Only the current progress report is required."_ (Mark with '[x]' if this is a progress report. Leave '[ ]' if not explicitly mentioned. These 2 options are mutually exclusive — only one must be marked with '[x]'. Do not omit any options.)
**Date of this report:** [date of this report] (Print the date in DD/MM/YYYY format. Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
**2. Client details**
**Client name:** [client's full name] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
**Claim number:** [client's ACC claim number] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
**Date of injury:** [client's date of injury] (Print the date in DD/MM/YYYY format. Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
**Client email:** [client's email address] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
**3. Supplier Contact details**
**Supplier company name:** [supplier company name] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
**Service Delivery Company name:** [service delivery company name] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
**Lead Provider name:** [lead provider's full name] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
**Lead Provider email address:** [lead provider's email address] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
**Lead Provider discipline:** [lead provider's clinical discipline] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
**Lead Provider phone:** [lead provider's phone number] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
**4. Overall objectives**
_"What is the overall objective specified in the referral?"_
(Mark with '[x]' based on information explicitly mentioned in the transcript, contextual notes, or clinical note. You may mark more than one of the following options. Do not omit any options.)
[ ] Same job, same employer (Mark with '[x]' if the objective is the same job with the same employer. Leave '[ ]' if not explicitly mentioned. Do not omit any options.)
[ ] Modified job, same employer (Mark with '[x]' if the objective is a modified job with the same employer. Leave '[ ]' if not explicitly mentioned. Do not omit any options.)
[ ] New job, same employer (Mark with '[x]' if the objective is a new job with the same employer. Leave '[ ]' if not explicitly mentioned. Do not omit any options.)
[ ] Other (Mark with '[x]' if the objective is something other than those listed above. Leave '[ ]' if not explicitly mentioned. Do not omit any options.)
**Comment:**
[comment on overall objectives] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
**5. Relevant contacts involved in the client's rehabilitation**
[relevant contacts involved in the client's rehabilitation] (Format each contact as a new row in a five-column markdown table. The columns are: Name of person, Role, Email, Phone, and Date of contact. Print all dates in DD/MM/YYYY format. Use a hyphen "-" for any fields that are not mentioned. Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
**6. Initial assessment**
**Date of initial assessment:** [date of initial assessment] (Print the date in DD/MM/YYYY format. Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
**Return to work target date on referral:** [return to work target date on referral] (Print the date in DD/MM/YYYY format. Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
**Return to work target date following assessment:** [return to work target date following assessment] (Print the date in DD/MM/YYYY format. Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
**Clinical reason for the new target date:**
[clinical reason for the new return to work target date] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
**Return to Work Plan:**
[return to work plan] (Format each period of the return to work plan as a new row in a five-column markdown table. The columns are: Dates, Days to work, Hours per day, Work tasks, and Details of restrictions and rehabilitation. Print all dates in DD/MM/YYYY format. Use a hyphen "-" for any fields that are not mentioned. Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
**<u>Assessment summary of the client and the workplace</u>**
**Brief injury history and functional presentation**
[brief injury history and functional presentation] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
**Physical Function:**
[client's physical function] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
**Orebro score:**
[client's Orebro Musculoskeletal Pain Screening Questionnaire score and interpretation] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank. A score greater than 50 indicates a higher estimated risk for future work disability.)
**Medication:**
[client's current medications] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
**Pain:**
[description of the client's pain] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
**Sleep:**
[description of the client's sleep] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
**Transport:**
[description of the client's transport situation] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
**Activities of Daily Living (ADLs):**
[description of the client's activities of daily living] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
**Psychosocial factors:**
[description of psychosocial factors relevant to the client's rehabilitation] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
**Medical certificate status**
[client's current medical certificate status] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
**Pre-injury role title**
[client's pre-injury role title] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
**Normal working hours/days**
[client's normal working hours and days in the pre-injury role] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
**Work tasks of the role**
[work tasks of the client's pre-injury role] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
**Physical and cognitive demands of the role**
[physical and cognitive demands of the client's pre-injury role] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
**Barriers and opportunities identified at assessment**
Barriers in engaging in the return to work programme or achieving a return to work:
[barriers identified in engaging in the return to work programme or achieving a return to work] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
Opportunities to address these barriers and achieve a successful outcome:
[opportunities identified to address barriers and achieve a successful outcome] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
**7. Activities to help achieve the overall objective and address any identified barriers**
[initial activities to help achieve the overall objective and address any identified barriers] (Format each activity as a new row in a three-column markdown table. The columns are: List of initial activities, Proposed completion date of the activity, and Detail the outcome of activity and how this will achieve the overall objective. Print all dates in DD/MM/YYYY format. Use a hyphen "-" for any fields that are not mentioned. Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
**Is a Work Specific Functional Rehabilitation required as part of this service?**
(Mark with '[x]' based on information explicitly mentioned in the transcript, contextual notes, or clinical note. Only one of the following options must be marked with '[x]'. Do not mark more than one. Do not omit any options.)
[ ] Yes (Mark with '[x]' if a work specific functional rehabilitation programme is required as part of this service. Leave '[ ]' if not explicitly mentioned. These 2 options are mutually exclusive — only one must be marked with '[x]'. Do not omit any options.)
[ ] No (Mark with '[x]' if a work specific functional rehabilitation programme is not required as part of this service. Leave '[ ]' if not explicitly mentioned. These 2 options are mutually exclusive — only one must be marked with '[x]'. Do not omit any options.)
**If yes, provide the reason the programme is required:**
[reason why the work specific functional rehabilitation programme is required] (Only include if the work specific functional rehabilitation question above is marked '[x]' for Yes. If marked '[x]' for No, omit this placeholder but retain the heading and leave blank. Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
_"If yes, complete the table below"_
(Only include the following table if the work specific functional rehabilitation question above is marked '[x]' for Yes. If marked '[x]' for No, omit the table entirely.)
[work specific functional rehabilitation details] (Format each work task as a new row in a three-column markdown table. The columns are: Work Task, Client's current ability to undertake the task, and Specific functional activities to be undertaken. Use a hyphen "-" for any fields that are not mentioned. Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
**8. Progress report**
(Only include this section if Progress is marked '[x]' in section 1. If Initial is marked '[x]' in section 1, omit this section entirely.)
"Please provide a progress update to ACC and/or make a request for further services."
**Date of report:** [date of progress report] (Print the date in DD/MM/YYYY format. Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
**Progress report number:** [progress report number in the format X of Y, where X is the current report number and Y is the total] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
**Progress since previous report:**
[progress since the previous report] (Describe progress towards the overall objectives and any relevant updates. Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
**Current return to work target date:** [current return to work target date] (Print the date in DD/MM/YYYY format. Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
**Has the return-to-work target date changed?**
(Mark with '[x]' based on information explicitly mentioned in the transcript, contextual notes, or clinical note. Only one of the following options must be marked with '[x]'. Do not mark more than one. Do not omit any options.)
[ ] Yes (Mark with '[x]' if the return-to-work target date has changed. Leave '[ ]' if not explicitly mentioned. These 2 options are mutually exclusive — only one must be marked with '[x]'. Do not omit any options.)
[ ] No (Mark with '[x]' if the return-to-work target date has not changed. Leave '[ ]' if not explicitly mentioned. These 2 options are mutually exclusive — only one must be marked with '[x]'. Do not omit any options.)
_"If yes, please give details as to why and update the return-to-work plan in the table below"_
(Only include the following details and table if the return-to-work target date changed question above is marked '[x]' for Yes. If marked '[x]' for No, omit the placeholder and table entirely.)
[details of why the return-to-work target date has changed] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
[updated return to work plan] (Format each period of the updated return to work plan as a new row in a five-column markdown table. The columns are: Dates, Days to work, Hours per day, Work tasks, and Details of restrictions and rehabilitation. Print all dates in DD/MM/YYYY format. Use a hyphen "-" for any fields that are not mentioned. Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
**Has the client's medical practitioner approved the return-to-work plan?**
_"(If yes, please submit with the report)"_
(Mark with '[x]' based on information explicitly mentioned in the transcript, contextual notes, or clinical note. Only one of the following options must be marked with '[x]'. Do not mark more than one. Do not omit any options.)
[ ] Yes (Mark with '[x]' if the client's medical practitioner has approved the return-to-work plan. Leave '[ ]' if not explicitly mentioned. These 2 options are mutually exclusive — only one must be marked with '[x]'. Do not omit any options.)
[ ] No (Mark with '[x]' if the client's medical practitioner has not approved the return-to-work plan. Leave '[ ]' if not explicitly mentioned. These 2 options are mutually exclusive — only one must be marked with '[x]'. Do not omit any options.)
**If no, please state why:**
[reason why the client's medical practitioner has not approved the return-to-work plan] (Only include if the medical practitioner approval question above is marked '[x]' for No. If marked '[x]' for Yes, omit this placeholder but retain the heading and leave blank. Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
**Is a further service level requested?**
(Mark with '[x]' based on information explicitly mentioned in the transcript, contextual notes, or clinical note. Only one of the following options must be marked with '[x]'. Do not mark more than one. Do not omit any options.)
[ ] No further service required (Mark with '[x]' if no further service is required. Leave '[ ]' if not explicitly mentioned. These 7 options are mutually exclusive — only one must be marked with '[x]'. Do not omit any options.)
[ ] SAW 2 — _"no prior approval required"_ (Mark with '[x]' if Stay at Work level 2 is being requested. Leave '[ ]' if not explicitly mentioned. These 7 options are mutually exclusive — only one must be marked with '[x]'. Do not omit any options.)
[ ] SAW 3 (Mark with '[x]' if Stay at Work level 3 is being requested. Leave '[ ]' if not explicitly mentioned. These 7 options are mutually exclusive — only one must be marked with '[x]'. Do not omit any options.)
[ ] SAW Exceptional (Mark with '[x]' if Stay at Work Exceptional is being requested. Leave '[ ]' if not explicitly mentioned. These 7 options are mutually exclusive — only one must be marked with '[x]'. Do not omit any options.)
[ ] SAW Initial Functional Rehab (Mark with '[x]' if Stay at Work Initial Functional Rehabilitation is being requested. Leave '[ ]' if not explicitly mentioned. These 7 options are mutually exclusive — only one must be marked with '[x]'. Do not omit any options.)
[ ] SAW Follow-up Functional Rehab (Mark with '[x]' if Stay at Work Follow-up Functional Rehabilitation is being requested. Leave '[ ]' if not explicitly mentioned. These 7 options are mutually exclusive — only one must be marked with '[x]'. Do not omit any options.)
[ ] Other (Mark with '[x]' if another service level not listed above is being requested. Leave '[ ]' if not explicitly mentioned. These 7 options are mutually exclusive — only one must be marked with '[x]'. Do not omit any options.)
**Provide a detailed reason for requesting additional services:**
[detailed reason for requesting additional services] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
[added activities and their proposed completion dates and expected outcomes] (Format each added activity as a new row in a three-column markdown table. The columns are: List of added activities, Proposed completion date of the activity, and Detail the outcome of activity and how this will achieve the overall objective. Print all dates in DD/MM/YYYY format. Use a hyphen "-" for any fields that are not mentioned. Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
**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:** [provider's full name] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
**Provider discipline:** [provider's clinical discipline] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
**Signature:**
**Date:** [date of signature] (Print the date in DD/MM/YYYY format. Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
"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. We use the information collected on this form to fulfil the requirements of the Accident Compensation Act 2001."
**Items for Clinician Review**
[checklist of items requiring clinician verification before finalising] (Print each flagged item on its own line beginning with '-' (bullet point), followed by the section name and a brief description of what the clinician needs to verify. Flag any content where review is warranted before sign-off. Examples of what to flag include: identity and demographic details that were unclear, partial, or potentially misheard, such as patient name spelling, NHI number, ACC claim number, date of birth, contact details, or address; dates that were spoken partially or ambiguously, such as "the third of the third" without a year, "last Tuesday" without an explicit date, date of injury, date of first treatment, date of assessment, or follow-up review date; mechanism of injury described vaguely or incompletely, such as "twisted awkwardly" without direction or load, "fell" without specifying surface or height, or a mechanism inferred from outcome rather than stated; diagnoses lacking specificity, such as body region without side, "shoulder pain" without specifying which shoulder, a general diagnosis without laterality, chronicity, or grade, or a working diagnosis where a definitive one is expected; numerical values that were partial, unclear, or potentially misheard, such as pain scores, range of motion in degrees, strength grades, blood pressure readings, medication doses, dosing frequencies, sessions per week, hours per day, percentage ratings, or impairment ratings; codes or classifications mentioned but not clearly stated, such as Read codes, ICD codes, work capacity percentages, whole-person impairment ratings, or ACC-specific category codes; provider details that were not fully stated, such as referring practitioner name and provider number, signing clinician designation, ACC provider ID, or supplier ID; functional capacity or independence ratings where the spoken value was indistinct, where multiple ratings were given without clarifying which was final, or where a rating was implied but not explicitly stated; return-to-work plan elements partially captured, such as target return date, hours per day, days per week, modified duties, lifting or postural restrictions, graduated return phases, or review date; treatment plan details with potential ambiguity, such as medication name, dose, frequency, route, or duration; therapy modality, session count, frequency, or review point; equipment or aid prescriptions without size, model, or supplier; clinical content inferred from context rather than explicitly stated, such as an assumed diagnosis based on described symptoms, an inferred mechanism, an inferred prior medical or surgical history, or an inferred medication based on a condition; conflicting or contradictory information across the transcript, contextual notes or clinical note, such as different dates of injury given at different points, conflicting body regions, conflicting laterality, or conflicting medication details; sections of the ACC form where expected information was not mentioned at all, such as consent confirmation, declaration date, clinician signature, mandatory demographic fields, or required outcome ratings; abbreviations, acronyms, or shorthand terms used by the clinician that may have multiple meanings or were not clearly resolved during the consultation; and any quoted values where the audio was likely affected by background noise, simultaneous speech, or the patient and clinician disagreeing on a detail. For each flagged item, name the section of the form it belongs to and describe the issue in one short sentence. If no items require review based on the transcript, contextual notes or clinical note, print "None flagged." beneath the section heading. Always include this section heading.)
(Always retain all section and sub-section headings in the output, regardless of whether content is available to populate them. If no information is explicitly mentioned for a given section or sub-section, leave the area beneath the heading blank but never remove the heading itself.)
