Department of and Industries ABILITY TO WORK Claims NON-ELIGIBLE PO Box 44291 ASSESSMENT Olympia WA CLOSING REPORT Do not use a cover or routing sheet Not for use with SAS3 closures Claim #: Worker Name: Claim Unit: Worker Age: Date of Injury: Job at time of injury: Work pattern at time of injury per week: Full time Part time Assigned VRC Name Assigned VRC Signature: (Printed or typed): VRC Phone # and Extension: VRC FAX #: Vocational Firm Provider & Branch #: Report Date: Recommended Outcome Code: Recommended Outcome Code Narrative: Return to Work Date: Name of Employer: Monthly Wages at Date of Injury: Monthly for Return to Work: Job Possibilities the Worker is Qualified for: Was all missing information explained? Yes No WorkSource Visit Date: Job Search Tools Used: Resume Assistance Date: Resume Attached? Yes No Date of Referral: Intake Date: Date Job Analyses(JA) Sent to Attending Physician Date Job Analyses (JA) Addressed by Attending Physician (AP): (AP):
Department of and Industries Claims PO Box 44291 Olympia WA ABILITY TO WORK NON-ELIGIBLE ASSESSMENT CLOSING REPORT Do not use a cover or routing sheet Not for use with SAS3 closures Claim #: Worker Name: Claim Unit: Worker Age: Date of Injury: Job at time of injury: Work pattern at time of injury Full time Part time per week: Assigned VRC Name (Printed or typed): Assigned VRC Signature: VRC Phone # and Extension: VRC FAX #: Vocational Firm Provider & Branch #: Report Date: Recommended Outcome Code: Recommended Outcome Code Narrative: Return to Work Date: Name of Employer: Monthly Wages at Date of Injury: Monthly for Return to Work: Job Possibilities the Worker is Qualified for: Was all missing information explained? Yes No WorkSource Visit Date: Job Search Tools Used: Resume Assistance Date: Resume Attached? Yes No Date of Referral: Intake Date: Date Job Analyses(JA) Sent to Attending Physician (AP): Date Job Analyses (JA) Addressed by Attending Physician (AP):
NonEligibleAwaTemplateNov092016.docx