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Rehabilitation assessment/examination (SRC116)


This form is used to engage an approved workplace rehabilitation provider, medical practitioner or a panel of suitably qualified persons to assess an injured or ill employee's readiness and capacity to participate in a rehabilitation program.

Available formats

Below is a completed sample of this form.

The Rehabilitation Assessment/Examination Referral Form (SRC 116) has been revised following an extensive consultation process during 2012, in line with the Guidelines for Rehabilitation Authorities 2012. Comcare welcomes feedback from users of this form. Your feedback should be forwarded to the Injury Management Advisory Service (IMAS) at

Last updated: October 2019

If you would like to request this publication in a different format to what is available for download (above), or the publication is not currently available for download, please refer to:

Page last updated: 17 Feb 2020