2C. Identify ongoing treatment and the impact on ability to work. 2D. Identify available independent medical examinations (IMEs) and summarize the ability to work opinions. Include IMEs conducted only the worker achieved maximum abilities. Are AP work Did AP review Opinion regarding ability to work IME Provider Specialty restrictions in line Date the IME? with IME? Yes Yes No No No response Yes Yes No No No response VOCATIONAL INFORMATION Address vocational information impacting the worker’s ability to work. 3A. Education Name and Location of High School Yes If yes, year: Graduated? No If no, last grade completed: Yes If yes, year: GED? No school or vocational training: (college, business school, military, OJT, etc.) Certificate or attended Transcripts Name/Type/Location Completed Degree Issued From/To obtained? Major/Subjects Yes Yes No No Yes Yes No No If applicable, explain why transcripts are unavailable. 3B. Identify non-work related activities such as hobbies or volunteer experience(s). Activity/experience Skills acquired 3C. List each position in the work history starting with the oldest. Address any gaps in employment.
2C. Identify ongoing treatment and the impact on ability to work. 2D. Identify available independent medical examinations (IMEs) and summarize the ability to work opinions. Include IMEs conducted only the worker achieved maximum abilities. Date IME Provider Specialty Opinion regarding ability to work Did AP review the IME? Are AP work restrictions in line with IME? Yes No Yes No No response Yes No Yes No No response VOCATIONAL INFORMATION Address vocational information impacting the worker’s ability to work. 3A. Education Name and Location of High School Graduated? Yes If yes, year: No If no, last grade completed: GED? Yes If yes, year: No school or vocational training: (college, business school, military, OJT, etc.) attended From/To Name/Type/Location Completed Certificate or Degree Issued Major/Subjects Transcripts obtained? Yes No Yes No Yes No Yes No If applicable, explain why transcripts are unavailable. 3B. Identify non-work related activities such as hobbies or volunteer experience(s). Activity/experience Skills acquired 3C. List each position in the work history starting with the oldest. Address any gaps in employment.
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