Online Referral Form - NAB

Employee details
Employee First Name*
Employee Last Name*
Employee Job Title
Employee ID
Employee Date of Birth
DD slash MM slash YYYY
Employee Work Address*
Street Address City State / Province / Region ZIP / Postal Code
Employee Email Address
Employee Office Phone Number*
Employee Mobile Number*
Cost Centre
Business Unit
Date of Injury
DD slash MM slash YYYY
Nature of condition / injury*
Incident Report Number*
Return to Work Status
Return to Work Status - additional information
Has a workers compensation claim been lodged?
- Yes
- No
Any workplace relations involved?
- Yes
- No

People Leader details
People Leader First Name
People Leader Last Name
People Leader Email
People Leader Phone Number
People Leader Mobile Number
Is the People Leader's work address the same as the employee's work address?
- Yes
- No
If "No" please enter the People Leader work address details below.
People Leader Work Address
Street Address City State / Province / Region ZIP / Postal Code

Referrer details
Is the Referrer the same as the IMC?*
- Yes
- No
If "No" please enter the Referrer details below.
Referrer Name
Referrer Phone Number
Referrer Email
Referrer Fax Number
Confirm and Send
Check all your details provided are correct and click 'Submit Referral'.

A copy of this form will be sent to the Injury Management
Consultant email address provided in this online form

Online Referral Form – NAB