Job Modification Assistance Application {F245-346-000}

F245-346-000 - JOB MODIFICATION ASSISTANCE APPLICATION. This form is used to request financial assistance for modifying a worker’s job duties, tools, or worksite to accommodate medical restrictions resulting from a workplace injury or occupational illness. This program helps injured workers return to or stay at work by covering the cost of essential equipment, training, or jobsite modifications—up to a maximum of $10,000, unless there are multiple job sites involved. The application should be submitted only if the worker’s claim is or was open at the time of the modification, the equipment requested is directly related to accepted conditions on the claim, there is an active employer-employee relationship, and the request is limited to necessary items rather than conveniences. Additionally, the worker must have received time-loss or loss-of-earning-power benefits while off work. To apply, the form must include detailed information about the worker, job title, claim number(s), and specific work restrictions. A list of requested accommodations—such as tools, equipment, training, or installation—is required, along with an itemized cost breakdown. Supporting documentation must also be attached, including a consultation or narrative report justifying the request, a vendor bid (and a second bid for any item over $2,500), and a signed Job Modification Ownership Agreement. This agreement outlines who will own the equipment upon the worker’s successful return to work, with general preference for the worker to retain ownership of portable items, while affixed or employer-funded items remain with the employer. The vendor providing the items must be an approved L&I provider, and billing must be submitted on the designated L&I form using the correct procedure code. www.FormsWorkflow.com