5D. JA Previous/Transferable Skills Jobs 5I. Testing Report Job Mod/Pre-Job Consultation 5E. 5J. (describe below) Report Acronym Key AP Attending physician ATW Able to work DOI Date of injury DOT Dictionary of Occupational Titles LMS Labor market survey JA Job analysis JOI Job at time of injury IME Independent medical examination OJT On-the-job training RTW Return to work SNA Services not appropriate SVP Specific vocational preparation time VRC Vocational rehabilitation counselor FCE Functional Capacity Evaluation Instructions Do not include the instructions when submitting your closing report. Do not copy and case notes, progress reports or entire medical reports in sections 1-3. Create additional rows or boxes in the form if needed. Enter N/A if a box does not apply. Remember to provide an explanation when requested information is not obtained. See It is not necessary to attach a Routing or Cover Sheet with the recommendation because the information is included in the index. Cover Page Enter all information requested. Remember to provide an explanation when requested information is not obtained. Return to work date: required for RTW outcomes. Monthly Wages for Return to Work: required for RTW outcomes. WorkSource Visit Date: If unable, please explain why in the space provided. Job Search Tools Used: If unable, please explain why in the space provided. Job Possibilities that the Worker is qualified for: required for all outcomes.
5D. JA Previous/Transferable Skills Jobs 5I. Testing Report 5E. Job Mod/Pre-Job Consultation Report 5J. (describe below) Acronym Key AP Attending physician ATW Able to work DOI Date of injury DOT Dictionary of Occupational Titles LMS Labor market survey JA Job analysis JOI Job at time of injury IME Independent medical examination OJT On-the-job training RTW Return to work SNA Services not appropriate SVP Specific vocational preparation time VRC Vocational rehabilitation counselor FCE Functional Capacity Evaluation Instructions Do not include the instructions when submitting your closing report. Do not copy and case notes, progress reports or entire medical reports in sections 1-3. Create additional rows or boxes in the form if needed. Enter N/A if a box does not apply. Remember to provide an explanation when requested information is not obtained. See It is not necessary to attach a Routing or Cover Sheet with the recommendation because the information is included in the index. Cover Page Enter all information requested. Remember to provide an explanation when requested information is not obtained. Return to work date: required for RTW outcomes. Monthly Wages for Return to Work: required for RTW outcomes. WorkSource Visit Date: If unable, please explain why in the space provided. Job Search Tools Used: If unable, please explain why in the space provided. Job Possibilities that the Worker is qualified for: required for all outcomes.
NonEligibleAwaTemplateNov092016.docx