Department of Labor and Industries Time Encumbrance Claims Section PO Box 44269 Form Olympia WA 98504-4269 Original Revised Modified Early Termination This form contains auto-calculations Date Worker Name Claim # Modification(s) Time Frames Training Site Cost Other (specify) Plan Information Goal Start Date End Date Early Termination Date O’NET DOT# LEP Start Date Method Formal OJT Combined LEP End Date Plan length Start Dates End Dates Name of Training Provider(s) (# calendar (mm/dd/yyyy) (mm/dd/yyyy) days) 1. 2. 3. 4. Total 0 Vocational Provider Assigned VRC Name Signature Firm Provider # Branch # VRC # VRC Phone # VRC Fax # Department Use Only VSS Signature Date Approved Not Approved VSS Comments
Department of Labor and Industries Claims Section PO Box 44269 Olympia WA 98504-4269 Time Encumbrance Form Original Revised Modified Early Termination This form contains auto-calculations Date Worker Name Claim # Modification(s) Time Frames Training Site Cost Other (specify) Plan Information Goal Start Date End Date O’NET Early Termination Date DOT# LEP Start Date Method Formal OJT Combined LEP End Date Name of Training Provider(s) Start Dates (mm/dd/yyyy) End Dates (mm/dd/yyyy) Plan length (# calendar days) 1. 2. 3. 4. Total 0 Vocational Provider Assigned VRC Name Signature Firm Provider # Branch # VRC # VRC Phone # VRC Fax # Department Use Only VSS Signature Date Approved Not Approved VSS Comments