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SOCSO RETURN TO WORK REFERRAL E-FORM
This form has been closed. Kindly visit our website rtwsocso@perkeso.gov.my to refer yourself or employee/friends to RTW Program.
BORANG ATAS TALIAN RETURN TO WORK PERKESO
Borang ini telah ditutup. Sila layari laman web kami rtwsocso@perkeso.gov.my untuk merujuk diri anda atau pekerja/rakan ke Program RTW.
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REFEREE INFO
*You need to complete the information below for our references
Q2. SOCSO State Office
*
KANGAR
Select the SOCSO State Office nearest to your or Insured Person/Patient/Employee location for the referral
Q2. SOCSO State Office
*
ALOR SETAR
KULIM
SUNGAI PETANI
Select the SOCSO State Office nearest to your or Insured Person/Patient/Employee location for the referral
Q2. SOCSO State Office
*
GEORGETOWN
SEBERANG JAYA
Select the SOCSO State Office nearest to your or Insured Person/Patient/Employee location for the referral
Q2. SOCSO State Office
*
IPOH
SRI MANJUNG
TAIPING
TAPAH
TELUK INTAN
KUALA KANGSAR
Select the SOCSO State Office nearest to your or Insured Person/Patient/Employee location for the referral
Q2. SOCSO State Office
*
KUALA TERENGGANU
KEMAMAN
Select the SOCSO State Office nearest to your or Insured Person/Patient/Employee location for the referral
Q2. SOCSO State Office
*
KOTA BHARU
KUALA KRAI
Select the SOCSO State Office nearest to your or Insured Person/Patient/Employee location for the referral
Q2. SOCSO State Office
*
BENTONG
KUANTAN
TEMERLOH
Select the SOCSO State Office nearest to your or Insured Person/Patient/Employee location for the referral
Q2. SOCSO State Office
*
BATU PAHAT
JOHOR BAHRU
KLUANG
MUAR
SEGAMAT
Select the SOCSO State Office nearest to your or Insured Person/Patient/Employee location for the referral
Q2. SOCSO State Office
*
MELAKA
Select the SOCSO State Office nearest to your or Insured Person/Patient/Employee location for the referral
Q2. SOCSO State Office
*
SEREMBAN
KUALA PILAH
Select the SOCSO State Office nearest to your or Insured Person/Patient/Employee location for the referral
Q2. SOCSO State Office
*
PETALING JAYA
KLANG
RAWANG
Select the SOCSO State Office nearest to your or Insured Person/Patient/Employee location for the referral
Q2. SOCSO State Office
*
KOTA KINABALU
SANDAKAN
KENINGAU
LAHAD DATU
TAWAU
Select the SOCSO State Office nearest to your or Insured Person/Patient/Employee location for the referral
Q2. SOCSO State Office
*
KUCHING
MIRI
SIBU
BINTULU
Select the SOCSO State Office nearest to your or Insured Person/Patient/Employee location for the referral
Q2. SOCSO State Office
*
KUALA LUMPUR
Select the SOCSO State Office nearest to your or Insured Person/Patient/Employee location for the referral
Q2. SOCSO State Office
*
PUTRAJAYA
Select the SOCSO State Office nearest to your or Insured Person/Patient/Employee location for the referral
Q1. Referee name (Doctor/ Employer's name/Workers/Public)
*
Q2. Hospital / Health Clinic / Company/ Others
*
Q3. Department
*
Q4. Referee Phone Number
*
-
Area Code
Phone Number
Q5. Referee Email
*
example@example.com
Q6. Referee Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Insured Person/Patient/Employee Info
*You need to complete the information of the insured person/patient/employee for our references.
Q1. Insured/Patient/ Employee's name
*
Q2. I/C Number
*
(xxxxxxxxxxxx)
Q3. Phone Number
*
-
Area Code
Phone Number
Q4. Email
*
example@example.com
Q5. Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Q6. SOCSO State Office
*
KANGAR
Select the SOCSO State Office nearest to your or Insured Person/Patient/Employee location for the referral
Q6. SOCSO State Office
*
ALOR SETAR
KULIM
SUNGAI PETANI
Select the SOCSO State Office nearest to your or Insured Person/Patient/Employee location for the referral
Q6. SOCSO State Office
*
GEORGETOWN
SEBERANG JAYA
Select the SOCSO State Office nearest to your or Insured Person/Patient/Employee location for the referral
Q6. SOCSO State Office
*
IPOH
SRI MANJUNG
TAIPING
TAPAH
TELUK INTAN
KUALA KANGSAR
Select the SOCSO State Office nearest to your or Insured Person/Patient/Employee location for the referral
Q6. SOCSO State Office
*
KUALA TERENGGANU
KEMAMAN
Select the SOCSO State Office nearest to your or Insured Person/Patient/Employee location for the referral
Q6. SOCSO State Office
*
KOTA BHARU
KUALA KRAI
Select the SOCSO State Office nearest to your or Insured Person/Patient/Employee location for the referral
Q6. SOCSO State Office
*
BENTONG
KUANTAN
TEMERLOH
Select the SOCSO State Office nearest to your or Insured Person/Patient/Employee location for the referral
Q6. SOCSO State Office
*
BATU PAHAT
JOHOR BAHRU
KLUANG
MUAR
SEGAMAT
Select the SOCSO State Office nearest to your or Insured Person/Patient/Employee location for the referral
Q6. SOCSO State Office
*
MELAKA
Select the SOCSO State Office nearest to your or Insured Person/Patient/Employee location for the referral
Q6. SOCSO State Office
*
SEREMBAN
KUALA PILAH
Select the SOCSO State Office nearest to your or Insured Person/Patient/Employee location for the referral
Q6. SOCSO State Office
*
PETALING JAYA
KLANG
RAWANG
Select the SOCSO State Office nearest to your or Insured Person/Patient/Employee location for the referral
Q6. SOCSO State Office
*
KOTA KINABALU
SANDAKAN
KENINGAU
LAHAD DATU
TAWAU
Select the SOCSO State Office nearest to your or Insured Person/Patient/Employee location for the referral
Q6. SOCSO State Office
*
KUCHING
MIRI
SIBU
BINTULU
Select the SOCSO State Office nearest to your or Insured Person/Patient/Employee location for the referral
Q6. SOCSO State Office
*
KUALA LUMPUR
Select the SOCSO State Office nearest to your or Insured Person/Patient/Employee location for the referral
Q6. SOCSO State Office
*
PUTRAJAYA
Select the SOCSO State Office nearest to your or Insured Person/Patient/Employee location for the referral
Q7. Purpose of referral / Support needed
*
Rehabilitation
Vocational
Refer to Rehabilitation Centre/Satellite SOCSO
Work modification (Work Integration)
Orthotic/ Prosthetic/ Assistive device
Work Support Integration (Job Coaching)
Psychology Support
Entrepreneurship
Q8. Diagnosis/Types of injury
*
Injury/ Illness
Q9. Remarks
Any additional information
Q10. Upload patient/employee's document (e.g.,memo/ letter/ medical report/ related documents)
*
Browse Files
Must not exceed 10MB
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