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RTW SA Request
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Referrer Name (First, Last)
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Referrer Email
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Referrer Company/Insurer
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Referrer Phone number
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Worker Name (First, Last)
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Worker Claim number
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Referral Type
Pre-Injury Employer
Fit for Work
Restoration in the Community
Return to Work Assessment
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Worker condition/injury (date of injury)
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Interpreter Required (yes/no, language)
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Comments
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