Transitional Work Grant Program Corporate Analysis Questionnaire Work Sheet {BWC-3002}

Transitional Work Grant Program Corporate Analysis Questionnaire Work Sheet Company organization Company name Corporate office address City Name of company transitional work coordinator Hours of operation State Phone number Shifts st 1 Policy number Number of employees Industry type ZIP code Email address 2 nd 3 rd Related companies: You may add additional related companies on the back of the form. Name Policy number Name Name Policy number Policy number Number of employees Number of employees Number of employees Management/employee/union buy-in Support acknowledged from Management Yes No Safety committee Yes No List unions: You may add additional unions on back of form. Union 1 Union 2 Union 3 Do I need labor-management cooperative assistance Yes No Supervisor Yes No Workers Yes No Union Yes No N/A Wage continuation Yes No Union representative name Union representative name Union representative name Transitional work policies and procedures I have policies and procedures Yes No Policies and procedures need updated Yes No Request templates from BWC Yes No Resources to manage claims Managed care organization name Third-party administrator name Representative's name Representative's name Representative involved Yes No Representative involved Yes No BWC-3002 TWG-4 American LegalNet, Inc. www.FormsWorkFlow.com Transitional Work Grant Program Corporate Analysis Questionnaire Work Sheet Job analysis List most common jobs of injury 1. 2. 3. List positions or manual classifications List 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Request generic job analysis from BWC Job analysis Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No No No No Update Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No No No Needed Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No No No Community medical resources Identify preferred providers Emergency care name Urgent care name Physician's name Specialist's name Rehabilitation name Address Address Address Address Address Phone number Phone number Phone number Phone number Phone number Request a template from BWC Yes No Training List transitional work training needs Management Yes No I have training materials Yes No Language barriers Yes No Supervisors Yes No Type of training Workers Yes Classroom Employee manual Training verification Yes No No Union Yes Train the trainer Just in time training No Electronic Distance training Request templates from BWC Yes No BWC-3002 TWG-4 American LegalNet, Inc. www.FormsWorkFlow.com