Self Insurance Vocational Reporting Form {F207-190-000}

Department of Labor and Industries Self Insurance Section PO Box 44892 Olympia WA 98504-4892 Self Insurance Vocational Reporting Form Account Injured Workers Name VRC Provider ID: City State Zip VRC Phone Number: ( ) Voc Firm Number: Employer VRC Name: VRC Address: Vocational Firm Name: Injured Worker's Address: Legal Representative's Name: Attending Physician's Name: City Claim Number VRC Provider Number: Voc Firm Branch Number: Date of Injury: State Zip City City Injured Worker's Phone No. State Zip Legal Rep's Address: Physician's Address: State Zip Phone Number: ( ) Employer or Service Representative's Signature Legal Rep's Phone # ( ) Physician's Phone # ( ) Date: A. Assessment Report Check only one eligibility status and the single best reason for your recommendation based upon the availability of objective information. Please include all medical reports and claim documents in the Self Insurer's possession not previously forwarded to the Department. 1. 2. 3. 4. Worker returned to regular ongoing work in usual work pattern on ___/___/___ Priority #______ Worker can work based on transferable skills Worker is eligible for vocational services. CLSAW Not eligible for vocational services due to one of the following: Combined effects Pre-existing and progressive condition(s)/unrelated to this claim Worker's actions Post-injury conditions unrelated to this claim Direct effects of the industrial injury B. C. D. E. F. G. H. Valid job offer by employer within 15 days of eligibility determination/documentation attached Request for Plan Development Extension attached EVOC Temporary medical condition precludes vocational services condition CLSPD Related condition Unrelated Vocational Rehabilitation Plan attached for department review CLSPD Worker declined further services and elected Option 2 Benefits / Election Form attached OPTSL Vocational Rehabilitation Plan successfully completed / closing report and documentation attached VCLOS Vocational Rehabilitation Plan not successfully completed 1. 2. 3. VCLOS Plan not completed due to causes outside the worker's control/ documentation and closing report attached Plan not completed due to worker's actions / documentation and closing report attached Worker is employable / documentation and closing report attached (Complete Section A above) Costs Expended Total cost $________________ and time _______________ expended for the plan. Total time loss benefits paid during the plan: $_____________ Total vocational services costs paid since the worker was found eligible for services: $_____________ Total amount of Option 2 award $______________ / payment scheduled attached Option 2 retraining costs paid to date since claim closure F207-190-000 SI Vocational Reporting 04-2009 $ _____________ American LegalNet, Inc. www.FormsWorkFlow.com