ACC Stay at Work programme form

Employee has consented to their information being collected and shared for the purpose of this referral and communication regarding this service *

Employee's full name *

Employee's phone number *

Employee's email *

Employee's address *

Company name (employer) *

Company address *

Employee's ACC claim number *

Date of injury *

Attach copy of medical certificate *

Please select a file

It is mandatory to attach a copy of the medical certificate. We recommend PDF format with a max. file size of 20MB. If your files do not meet these requirements or you require assistance, please email nzreferrals@apmworkcare.co.nz.

Is this a work-related injury? *

Yes No

Employees current medical certification *

Full clearance Fit for selected work Fully unfit

Date valid until *

Referrer details

Your full name *

This will help us to complete the assessment with your involvement

Phone number *

Email *

Company name

(if different from employee details above)

Company address

(if different from employee details above)

Comments *

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By clicking submit I confirm I have read and understood APM’s privacy policy *

ACC Stay at WorkProgramme Referral Form

ACC Stay at Work
Programme Referral Form