Form F207-190-000 - Self Insurance Vocational Reporting Form
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1Self Insurance Vocational Reporting Form
Department of Labor and Industries
Self Insurance Section
PO Box 44892
Olympia WA 98504-4892
Employer
Account
Injured Workers Name
Claim Number
VRC Name:
VRC Provider ID:
VRC Provider Number:
VRC Address:
City
State
Zip
VRC Phone Number:
(
)
Vocational Firm Name:
Voc Firm Number:
Voc Firm Branch Number:
Injured Worker’s Address:
City
State
Zip
Injured Worker’s Phone No.
Date of Injury:
Legal Representative’s Name:
Legal Rep’s Address:
City
State Zip
Legal Rep’s Phone #
(
)
Attending Physician’s Name:
Physician’s Address:
City
State Zip
Physician’s Phone #
(
)
Employer or Service Representative’s Signature
Phone Number:
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.
Worker returned to regular ongoing work in usual work pattern on ___/___/___ Priority #______
2.
Worker can work based on transferable skills
3.
Worker is eligible for vocational services.
CLSAW
4.
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.
Valid job offer by employer within 15 days of eligibility determination/documentation attached
C.
Request for Plan Development Extension attached
EVOC
D.
Temporary medical condition precludes vocational services
Related condition
Unrelated
condition
CLSPD
E.
Vocational Rehabilitation Plan attached for department review
CLSPD
F.
Worker declined further services and elected Option 2 Benefits / Election Form attached
OPTSL
G.
Vocational Rehabilitation Plan successfully completed / closing report and documentation attached
VCLOS
H.
Vocational Rehabilitation Plan not successfully completed
VCLOS
1.
Plan not completed due to causes outside the worker’s control/ documentation and closing report attached
2.
Plan not completed due to worker’s actions / documentation and closing report attached
3.
Worker is employable / documentation and closing report attached (Complete Section A above)
Costs Expended
T
otal 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
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