Your claim number is 100 5253 5290

11 May 2021

Ms Paula Ossandon
168 The Ridgeway
Mornington
Wellington 6021

Dear Ms Ossandon

We’ve received your claim, but need a bit more information

Your treatment provider has made a claim on your behalf for the following medical condition,
which you’ve told them happened because of your work:
Sprain, shoulder joint
Subacromial impingement

We’re sorry to hear this and will assess your claim as quickly as we can. Before we can do
that, we need some more information.

What we need
To help us assess your claim, we need you to:
complete the ACC272 Cover questionnaire
arrange for your supervisor or manager to complete the ACC273 Employer cover
questionnaire and work injury report for employed claims only

We have arranged for your doctor to complete a medical questionnaire and provide us with
relevant medical notes relating to your claim.
We’d appreciate it if you could return these forms to us by 1st June 2021.

If we don’t receive this supporting information we may have to decline the claim. It’s ok if you
need more time, but please let us know as soon as possible. When you’ve completed the
questionnaire, please return it in the pre-paid envelope supplied. Your doctor or employer
may decide to send their information separately.

What happens now

While assessing your claim, we may still be able to help pay for some medical treatment,
such as physiotherapy or chiropractor treatment. Please discuss your treatment needs with
your health professional and remember to take your claim number 100 5253 5290 along with
you to any treatment appointments.

WGP01CLT
Until your claim is approved we’re unable to provide assistance with loss of earnings. In the
meantime, if you’ve been off work for a week or more you’ll need to approach either your
employer or Work and Income for assistance.

If your claim is approved we may also be able to help with other support for your injury, so
please keep any receipts and medical certificates.

Enclosed information
We’ve enclosed the information sheet WGPIS01 Assessing cover for your work-related
gradual onset, disease or infection claim, which gives more information about how we
determine cover for these types of claims.

We’re happy to answer your questions

Please call me on Phone: 0800 474 792 if you’d like to talk about this letter. I’m happy to
answer any questions or, if you have any concerns, to work with you to resolve these.

Yours sincerely
Recovery Administration
On Behalf of

Work Related Gradual Process

Telephone: Phone: 0800 474 792

Encl. ACC272 Cover questionnaire, ACC273 Employer cover questionnaire and work injury
report, WGPIS01 Assessing cover for your work-related gradual onset, disease or infection
claim.

WGP01CLT
All about

Assessing cover for your work-related

gradual onset, disease or infection
claim
When we receive a work-related claim we first need to make sure the disease or infection occurred at
work and not elsewhere.

This information will help you understand what we need to know to determine cover and why.

Finding out about your condition

To assess the claim, we first collect information from everyone associated with the condition. This
includes medical professionals and employers. We do this to ensure we can make an informed
decision.

We need to find out:

the details of the medical condition, what it was and when it was first noticed
what caused it to develop.

Once we’ve collected information that establishes that the condition was due to your work we’ll be
able to approve the claim.

We’ll be unable to approve the claim if we find the condition was caused by an environment or
activity outside of work.

How we get this information

We’ll need the following forms completed.
Name of form How this form helps

Client cover questionnaire This form tells us all about your condition and how and where
(ACC272) you think it developed
Employer cover questionnaire and Your current and previous employers tell us about your job
work injury report (ACC273) tasks and any risks in your workplace
Medical practitioner questionnaire Your doctor tells us about your condition and provides us with
(ACC271) relevant medical records
Work-related exposure - client You tell us how, where and when you were exposed to a
questionnaire (ACC6220) substance that you think caused your condition to develop
Work-related exposure - employer Your current and previous employers provide information on
questionnaire (ACC6221) exposures to substances and the risks involved with your job
tasks and/or workplace environment

WGPIS01 – August 2018 This information may change and should only be used as a guide Page 1 of 2
All about Assessing cover for your work-related gradual onset, disease or
infection claim continued…
If the information about your condition isn’t complete
If there isn’t enough information about your condition in your forms or medical records to determine
cover for your claim, we can arrange for you to see a specialist. The specialist will assess your
condition and give us their opinion of the cause and may recommend what treatment you’ll need.

ACC will pay for the assessment and in some situations, may be able to help with the costs of getting
to and from the appointment.

How long before we make a decision?

Once we receive all the information you can expect a decision within 60 days. It can sometimes take
longer if we’re waiting on forms to be returned from medical professionals and employers or if we
need further clarification. If this happens, we’ll write to you to let you know how much more time we
need.

How will I know if ACC has approved my claim?

We’ll call or write to let you know of our decision, what help we’re able to provide and how to get it.

What happens if my claim isn’t approved?

We’ll also call or write and explain our decision. If you’re unhappy with our decision, we’ll work with
you to address your concerns. You’ll also have the right for the decision to be reviewed by an
independent reviewer.

We’re happy to answer your questions

If you have any language or cultural needs, let us know so we can help.

If you’d like to know more about our services, please call your client service staff member
directly or phone 0800 101 996. You may also find the following information helpful.

For information about… See the guide…

help we can provide Getting help after an injury (ACC2399 booklet)

how we collect and use your information Collection and disclosure of information
(INPIS01 - information sheet)
your rights to receive a high standard of Working together to resolve issues (ACC2393
service, and how we resolve any concerns booklet)
you may have

Copies are available at any ACC Branch, on our website acc.co.nz or by calling 0800 101 996.

WGPIS01 – August 2018 This information may change and should only be used as a guide Page 2 of 2
 ACC272
Client Cover Questionnaire
Please complete this form if you’ve lodged a claim for personal injury caused by a work-related gradual
process, disease or infection. ACC uses this information when assessing your claim.

1. Client details

Client name: Ms Paula Ossandon Claim number: 100 5253 5290

Residential address: 168 The Ridgeway, Date of birth: 30/06/1981

Mornington, Wellington, 6021

Postal address (if different to home address):

Home phone: Mobile phone: 027774140 Work Phone:

Employed Self-employed

Your occupation: Cleaning Supervisor Your occupation:

Pcs cleanning service ltda
Name of your employer: Your trading name:

Your employee number: 0212998700 Your ACC number: ZC97060

0800565758 Your IRD number: 126564465

Please provide a brief description of your occupation and work tasks:
My duty is to clean a school. My duties include: collecting and removing rubbish from rubbish bins and taking it to the outside container, cleaning
bathrooms, showers and kitchen (clean and desinfect all, wipe mirror, remove waste), swipe and mop the gym, cleaning windows and glass doors,
vacuum my entire designated building and cleaning the carpet when required. Then my duty is to check the other areas of the other workers and make
sure everything has been done properly, if not clean or else to nish their job.

2. Symptoms

What were the first symptoms you noticed relating to your condition?
shoulder pain and arm fatigue, shoulder inflammation radiating to the elbow.

When did you first notice the symptoms? Please provide a date if possible:
My rst discomfort in my shoulder was in December, but in February after the holidays I began to
have a stronger pain every day. it was something gradual.
How many hours a week were you working when you first noticed the symptoms?

Please indicate the spread of the hours, e.g. 8 hours per day; 12-hour shift 4 times a week; 5 hours for 2 days
1/2
plus 7 hours for 2 days:

Around 30 hours per week, but that varies if we have to cover someone that is off work (it often
happens) or there is extra work. A normal day between 4 or 5 hours and a busy day for example
Friday 7 hours and saturday only 2 hours.

Describe how your symptoms have changed over time, e.g. improved after stopping a particular activity:

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ACC272 Client Cover Questionnaire
I think I have improved my shoulder when I do not do a repetitive and constant exercise with my
arm and shoulder; for example using the vacuum cleaner for a long time, hours.

What do you believe caused these changes?

Resting; for example when I had my holidays break the pain went away for a little bit. It came back
when I came back to work. When I’m not over doing my arm like when I’m not carrying heavy bags or
vacuuming for long hours.

What work activities trigger your symptoms?

Long time using the Vaccum and removing big rubbish bags.

What non-work activities trigger your symptoms?

painting my house, I never did it again.

Do your symptoms change when you’re not at work? Yes No

If ‘yes’, please specify how:

Yes absolutely. my arm is more relaxed without feeling tense. the pain has gone down
because I don't do hard or fast tasks.

Is your condition: Improving About the same Getting worse

3. Treatment/Injury management details

What relieves your symptoms? For example, activities, treatment etc.:

Rest, gentle mobility exercises for my arm and posture, don’t do repetitive work for long time e.g
vacuum or polish and use some anti ammatory and pain pill.

Have you consulted a doctor about your condition? Yes No

If ‘yes’, please provide the date of your first consultation and the name and contact details for this doctor:

General Practitioner (GP) name: Dr. Colin Thomas Date:

21/04/21

GP or Primary Health Organisation (PHO) practice details:

If you haven’t seen a doctor about your condition, then you’ll need to do this within the next 6 working days.
This is so we can obtain medical information about your condition from your GP

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ACC272 Client Cover Questionnaire
Please provide the name and contact details of the doctor that you’ll be seeing:

General Practitioner (GP) name: Dr. Colin Thomas Date:

GP or Primary Health Organisation (PHO) practice details:

Is this the doctor who’ll be completing the GP questionnaire for this claim? Yes No

If ‘no’, please provide the name and contact details for the doctor who will be completing it:

Have you consulted a specialist about your condition? Yes Appointment made No

If ‘yes’ or ‘appointment made’, please provide the specialist’s name and address and the date of the
appointment:

Name: Address: Date:

What treatments are you having now, or have had in the past, for your condition?

The doctor told me that I should rest rst because my shoulder is swollen and very painful, which
prevents me from moving my arm well. I am taking panadol and ibuprofen. I have an appointment
tomorrow to have my shoulder injected. In 2017 or 2018 a doctor put an injection in my shoulder
without ultrasound guidance

4. Medical history

Have you suffered from similar conditions in the past? Yes No

If ‘yes’, please describe:

I don't remember 2017 or 2018, painting my new house my shoulder swelled, a “specialist” put an
injection at that time.

Who treated you for these conditions?

My GP and a specialist who was suggested by my GP of that time

5. Work details

Are you presently working? Yes No Full-time Part-time

Did you report the injury at your workplace? Yes No

Who did you report the injury to and when? I reported to my boss Date:
21/04/20
If you didn’t report your injury to anyone please explain why:

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ACC272 Client Cover Questionnaire
I did not consider it to be a serious injury, I just thought it was exhaustion from the hard work we do
and that I just needed to rest and it would pass. I asked my GP about my shoulder because the last
few days it hurt more than usual and I was not sleeping very well because of the pain. I went to my
new GP for something else and he detected that I had a serious problem with my shoulder.

Has anyone else in the workplace been affected? Yes No Don’t know Self-employed

When I commented on my shoulder pain, a workermate commented that she felt the same in her
vacuuming routine. Some time ago I commented that the routine is too much and hard for only one
person, especially when it is 4 continuous hours, I hope she does not have the same problem. I
suggested changes and reported that to Dave.

6. Work tasks

How long have you been doing the sort of work that you believe has caused or contributed to your condition?

About 15 months.

Describe your usual work tasks and the time spent on them. (Attach new page if needed).

Task Hours per day

Vacuum 2:30 to 4 o more

1 hours
Clean toilet and kitchen
30 minutes
Clean Windows and doors
45 minutes
Swip and mop gym
30 minutes
Rubbish
Do you have a second job or work activity? Yes No

If ‘yes’, please describe this job including your usual work tasks, the time you spend doing them, and your
employer’s name and contact details:

Have you ever worked outside of New Zealand doing similar work? Yes No

If ‘yes’, please give details including the job title, your work tasks, the time you spent doing them and the
dates:

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 ACC272 Client Cover Questionnaire

7. Injury details

Describe your condition or injury:

Severe pain in the shoulder with in ammation, over time has increased with small signals of “sort electricity”
going down to the elbow and ngers of the hand (middle nger and ring nger) I can detect that the pain
starts with repetitive movements when cleaning and vacuuming.

Hand Injuries: Some conditions or injuries may only affect one hand. Which hand you use most may
influence how much the condition or injury affects you and your recovery and return to work. For example, if
you suffer from carpel tunnel in your left hand but you’re right handed, you may find that it’s still possible or
easier to do some things with your right hand, whereas you wouldn’t if your right hand was affected

Are you right or left Right Left Ambidextrous

handed?

Please attach a copy of any Occupational Safety and Health accident or workplace assessment reports that
are relevant to this claim.

Which of the following activities do you do at work?

Activity Part of your Details of hours per day or % of day’s work

activities?

Keyboard use or data Yes No Hours or % per day: Time with no break:
entry
Ability to vary posture? Yes No

Handwriting Yes No Hours or % per day: Time with no break:

Ability to vary posture? Yes No

Using office equipment, Yes No List tasks:

e.g. telephone,
photocopier, mail opener,
filing etc.
Hours or % per day: Time with no break:

Ability to vary tasks? Yes No

Telephone headset used (if Yes No

relevant)?

Repetitive hand/arm Yes No List tasks:

Vacuum, mop, swipe the oor, dusting and
actions
cleaning surfaces

Hours or % per day: 4 or more Time with no break:Sometimes

Ability to vary tasks? Yes No

Forceful hand/arm actions Yes No List tasks: especially with the vacuum cleaner.

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ACC272 Client Cover Questionnaire

Hours or % per day:

4 or more Time with no break:
Yes,
sometimes.
Ability to vary tasks? Yes No

Power tool use Yes No

carpet machine moving back and forth,
Detail tools used:
removing clean and dirty water container from
the machine this was done in December with full
cleaning around 2 o 3 weeks we worked.
Hours or % per day: 4 Vibration: Yes No

Hand tool use Yes No Detail tools used:

Hours or % per day: Average weight of tools:

Tight pinch (finger) grips Yes No Number per hour: Time with no break:

Power hand grip Yes No Number per hour: Time with no break:

Overhead reaching and/or Yes No List tasks: Clean Windows and doors
working above bench
Deposit the rubbish in the big container.
height

Hours or % per day: 1 Time with no break:

Ability to vary tasks? Yes No

Kneeling Yes No Hours or % per day: Sometimes when picking papers, etc.
Walking or standing Yes No Hours or % per day: 4 to 7 or more.
Driving Yes No Hours or % per day:

8. Lifting activities

Lifting: It’s really important that we get a good idea of how often and what objects you lift or are expected to
lift when you’re at work

List objects lifted:

Rubbish bags
Vacuum cleaner

Number of lifts per day: 10 o more Time spent repeatedly lifting per hour: 1

Average weight lifted: 2 to 5 kgs aprox Maximum weight lifted and how often: around 5kg,
Every day
Height lifted from, e.g. from floor level: 1,70 mitres
Height lifted to, e.g. above chest height: 40 cm

Do you use any lifting devices? Yes No

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ACC272 Client Cover Questionnaire
If ‘yes’, please describe:

Do you do any awkward lifts? Yes No

If ‘yes’, please describe: I lift the rubbish bags to throw them into the outside bigger
rubbish container.

Do you have to bend or twist? Yes No

If ‘yes’, please describe and tell us how many hours per day: 30 minutes on1 hours.

Does the job require lifting at the same time as bending? Yes No

If ‘yes’, please provide details:

When you collect the rubbish from the floor to the container.

9. Workplace

Was there any change in workload or workplace layout prior to the onset or worsening Yes No
of symptoms?

If ‘yes’, please describe: Not really. Nothing has changed. I did suggested changes on the
workload and a trolley to transport heavy loads but nothing.

Is there anything unusual about your workplace, e.g. heat, cold, noise, or chemicals? Yes No

If ‘yes’, how long do you spend in this work environment?

10. Effect of condition on the ability to do your job

Have you had time off work due to this condition? Yes No

If ‘yes’, please provide details:

I am currently not working due to my inflammation and shoulder pain.

Are you presently doing alternate or selected duties? Yes No

If ‘yes’, please describe these duties:

The nature of work there is no alternative work. It all involves a strong movement for
my shoulder.

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ACC272 Client Cover Questionnaire

If you’re working different hours due to your condition, please tell us what the difference is between your
previous and current hours:

Previous hours: Hours now:

11. Work history

Please provide your full working history. Include every company you have worked for and any periods of self-
employment. Please enter all the details requested in the table below. (Attach new page if needed).

Employer’s name and address Job title Work tasks Date from Date to

Mop, dust, polish, swipe 17/02/20

Cleaning
Pcs cleanning service ltda Wipe,vacuum and Present
Supervisor
Desinfect.

(Don Taco) Kitchen Prepare dishes(pre-order) 21/12/20

24/02/20
Sebastian Romero assistent Wash dishes.
Mop, dust, polish,
Remington Commercial Wipe,vacuum and 07/06/19 02/20
Cleaner
Desinfect.
Operations Responsible for the
Claro chile External distributors of 2013 2017
manager
the company
Customer service Responsible to create a
Claro Chile supervisor positive Customer services 2008 2013
experiencie .

12. Non-work activity

There are activities we do when not working that may contribute or impact a condition or injury, e.g.
decorating or cleaning at home, digging or mowing the garden, sports and exercise. These activities may not
appear to be connected to a condition or injury but can contribute to making recovery take longer. We ask for
non–work activity information so we can get the big picture about your condition or injury.
So we can best support you and your claim, please describe any non-work activities under the following
headings. For each activity, please include the number of hours per week you do that activity and how you
travel there, if applicable.

Hobbies, e.g. gardening, music, dancing, sewing:

Activity: Travel: Hours per week: 1 o less

Gardening
Activity: Travel: Hours per week:

Sports, e.g. jogging, tennis, cycling, rugby:

Activity: Travel: Hours per week:

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 ACC272 Client Cover Questionnaire
Activity: Travel: Hours per week:

Unpaid/voluntary activities, e.g. study, club, church, caring for another person:

Activity: English study Travel: Hours per week: 2

Activity: Travel: Hours per week:

Household duties, e.g. childcare, cooking, cleaning, vacuuming:

3 o nothing
Activity: Casual babysitter 1 time per 3 week Hours per week: for week.
Activity: Clean and cook in my home Hours per week: 4

Home maintenance, e.g. decorating, car repairs. Please specify any power tools used:

Activity: Hours per week:

Activity: Hours per week:

13. Additional information

Please tell us anything you think may help us consider your claim. (Attach new page if needed).

I believe that the use of the vacuum cleaner in my workplace should be for a stronger person and or
not so many hours in a row to avoid a future injury. Avoid working against time to avoid a future
injury or danger to workers, if the routine requires more time, the employer must provide that extra
time to ful ll 100% of his duty. Use of adecuate tools to trasport heavy loads

14. Client Declaration

I declare that to the best of my knowledge the above particulars are true and correct and I have
not withheld any information likely to affect my claim.

Client consent for the collection and release of information

I authorise the collection and release of any information about me to the extent necessary to
assess my claim for cover, entitlement to compensation, rehabilitation assistance and medical
treatment.

I understand this authority relates to all aspects of my claim, and extends to any external
agencies or service providers, such as general practitioners, specialists, assessment agencies
and employers, and empowers those organisations or persons to provide the information
requested directly to ACC.

I understand that I have the right to access and ask for the correction of any information that
ACC holds about me. I understand that this authority is valid for the period ACC provides

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ACC272 Client Cover Questionnaire
assistance on this claim, unless I negotiate a different arrangement with my case manager.

Signature: Paula ossandon Date: 12/05/21

When we collect, use and store information, we comply with the Privacy Act 1993 and the Health Information Privacy
Code 1994. 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.

ACC272 August 2018 Page 10 of 10

ACC273
Employer Cover Questionnaire and
Work Injury Report
Please complete this form if you are the employer of Ms Paula Ossandon who has lodged a claim for personal
injury caused by a work-related gradual process, disease or infection. ACC uses this information when
assessing their claim.

ACC details

ACC Claims Management staff: Work Related Gradual Process Phone: 0800 474 792
email – [email protected]

Please complete the following details and return this form to us by 01/06/2021. Ms Paula Ossandon has given
ACC permission to collect information needed to determine cover for their injury, by completing the Patient
Declaration on the ACC45 ACC Injury claim form.

1. Client details

Client name: Ms Paula Ossandon Claim number: 100 5253 5290

Residential address: 168 The Ridgeway, Mornington, Wellington, Date of birth: 30/06/1981
6021

Nature of injury: Secondary-S507.-Sprain, shoulder joint- Date of injury: 22/02/2021

Right;Secondary-N2122-Subacromial impingement-Right

Home phone: Mobile phone: Work Phone:

Describe how the injury occurred:

Address where injury occurred:

2. Employer details

Registered trading name: Employer name:

Contact person:

Work phone: Mobile phone: Email:

ACC employer number (if not known, use employer IRD number):

Employer levy classification unit (Refer to ACC Employer levy classification booklet if needed):

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ACC273 Employer Cover Questionnaire and Work Injury Report
Type of business activity of employer, e.g. tyre retailing:

3. Client/employee details

Client’s employee number (if applicable):

How long has Ms Paula Ossandon been in your From: To:

employment?

In the following table, list the client’s daily work tasks and estimate how long they spend on each task.

Task Hours per day

4. Cause of injury

Do you consider the injury to be related to the client’s work tasks or work Yes No Unsure
environment?

If ‘No’ or ‘Unsure’, please provide reason(s):

Did the employee suffer from their condition before starting work with your Yes No Unsure
organisation?

Did the employee ever complain about the condition while in your employment? Yes No Unsure

Describe how the injury occurred:

Please describe any other possible cause of this injury or relevant information:

5. Work environment

Describe the environment the employee works in and note any unusual features, e.g. heat, cold, noise or
chemicals:

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ACC273 Employer Cover Questionnaire and Work Injury Report

For claims relating to exposure to chemicals etc., please attach copies of Material Data Safety Sheets for all
compounds.

Have these been attached? Yes No

6. Work activities

Activity Part of Details of hours per day or % of day’s work

employee’s
activities?

Keyboard use or data Yes No Hours or % per day: Time with no break:
entry
Ability to vary posture? Yes No

Handwriting Yes No Hours or % per day: Time with no break:

Ability to vary posture? Yes No

Using office equipment, Yes No List tasks:

e.g. telephone,
photocopier, mail opener,
filing etc.
Hours or % per day: Time with no break:

Ability to vary tasks? Yes No

Telephone headset used (if Yes No

relevant)?

Repetitive hand/arm Yes No List tasks:

actions

Hours or % per day: Time with no break:

Ability to vary tasks? Yes No

Forceful hand/arm actions Yes No List tasks:

Hours or % per day: Time with no break:

Ability to vary tasks? Yes No

Power tool use Yes No Detail tools used:

Hours or % per day: Vibration: Yes No

Hand tool use Yes No Detail tools used:

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ACC273 Employer Cover Questionnaire and Work Injury Report
Hours or % per day: Average weight of tools:

Tight pinch (finger) grips Yes No Number per hour: Time with no break:

Power hand grip Yes No Number per hour: Time with no break:

Overhead reaching and/or Yes No List tasks:

working above bench
height

Hours or % per day: Time with no break:

Ability to vary tasks? Yes No

Kneeling Yes No Hours or % per day:

Walking or standing Yes No Hours or % per day:

Driving Yes No Hours or % per day:

7. Lifting activities

Lifting: It’s really important that we get a good idea of how often and what objects the client lifted or was
expected to lift when at work.

Objects lifted:

Number of lifts per day: Time spent repetitively lifting per hour:

Average weight lifted: Maximum weight lifted and how often:

Height lifted from, e.g. from floor level:

Height lifted to, e.g. above chest height:

Lifting devices used? Yes No If ‘yes’, please describe:

Awkward lifts? Yes No If ‘yes’, please describe:

Bending or twisting? Yes No If ‘yes’, please describe and indicate hours per day:

Does the job require lifting at the same time as bending? Yes No

If ‘yes’, please provide details:

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ACC273 Employer Cover Questionnaire and Work Injury Report
Please detail any other relevant work activities.

8. Worksite assessment

Has this job been subject to any worksite assessments? If ‘Yes’, please enclose Yes No N/A
copies.

Are there any Occupational Safety Health or accident reports relating to this claim? Yes No N/A
If ‘Yes’, please enclose copies.

Has anyone else in your organisation, performing similar work, or working in the Yes No
same environment suffered from this condition?

9. Employer signature

Name:

Title:

Relationship to the employee, e.g. Manager, Supervisor:

Signature: Date:

When we collect, use and store information, we comply with the Privacy Act 1993 and the Health Information Privacy
Code 1994. 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.

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ACC271
Medical Practitioner Cover
Questionnaire
The treating medical practitioner needs to complete this form if the claim is for work-related gradual process,
disease or infection. ACC uses this information when assessing the claim.

ACC details

Claims Management staff: Work Related Gradual Process Phone: 0800 222 983 ext. [Extension]

Please complete the following details and return this form to us by [Return_Date]. Ms Paula Ossandon has
given ACC permission to collect information needed to determine cover for their injury, by completing the
Patient Declaration on the ACC45 ACC Injury Claim Form.

1. Client details

Client name: Ms Paula Ossandon Claim number: 100 5253 5290

Date of birth: 30/06/1981 Purchase order:

2. Injury details

Current diagnosis: Secondary-S507.-Sprain, shoulder joint-Right;Secondary-N2122-Subacromial

impingement-Right

Has this changed since claim lodgement?

Date first consulted about condition:

What symptoms did the patient describe?

What symptoms or signs from your examination findings support the current diagnosis and confirm there has
been a physical injury?

Have there been, or are you waiting on any investigations such as lab tests, a specialist assessment, worksite
assessment, dermatology patch testing or radiology examination?

Yes No If ‘yes’ please give details and provide a copy of any available reports:

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ACC271 Medical Practitioner Cover Questionnaire

Please provide details of any treatment given and the patient’s response:

Have you enclosed copies of all consultation notes and reports relevant to this claim? Yes

3. Other health problem or factors

What other health problems or factors may be contributing to your patient’s condition?

Obesity Diabetes Arthritis (specify) History of eczema Smoker

History of History of hay Thyroid disease Pregnancy Nil

asthma fever (specify)

Additional information and details of other relevant health problems or factors:

4. Medical Practitioner details

Name:

Practice address:

Signature: Date:

When we collect, use and store information, we comply with the Privacy Act 1993 and the Health Information Privacy
Code 1994. 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.

ACC271 August 2018 Page 2 of 2