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Application for Elective Coverage of Excluded Employments

Used by employers to request coverage of workers' compensation for non-mandatory employment. Shows a list of employment categories to choose from that are not included within the mandatory coverage of workers' compensation.



Form
F213-112-000
 
Application for Exclusion/Inclusion - Mandatory Coverage (Family Farm)

To exclude or include coverage for a family farm's children.



Form
F213-113-000
 
Record Keeping

Quick reference card: Identifies the type of records employers, including construction contractors, need to keep to allow L&I to compute premiums. This information is part of the publication, Workers’ Compensation Record Keeping and Report Guides.



Publication
F214-011-000
 
Excluded and Exempt Employments

Quick reference card: Provides a list of employments excluded from workers' compensation coverage, including those eligible for optional coverage. This information is part of the publication, Workers’ Compensation Record Keeping and Report Guides.



Publication
F214-013-000
 
Computing Worker Hours

Quick reference card: Shows employers how to figure workers' compensation premiums for different types of employees: hourly employees, salaried employees, commissioned personnel or employees paid for piecework. This information is part of the publication, Workers’ Compensation Record Keeping and Report Guides.



Publication
F214-014-000
 
Audit Reference Card
Quick reference card: Answers questions employers may have about audits L&I conducts to verify the that workers' hours have been reported correctly and workers' compensation premiums have been calculated accurately.

Publication
F214-020-000
 
Limited Liability Companies (LLC)

Quick reference card: Reviews the requirements for members or managers of limited liability companies to be exempt from workers' compensation (industrial insurance) coverage. This information is part of the publication, Workers’ Compensation Record Keeping and Report Guides.



Publication
F214-021-000
 
Drywall Contractors

Quick reference guide: Used by drywall contractors to get answers to questions about being a drywall contractor and how it relates to L&I.



Form
F214-024-000
 
Your Workers' Compensation Rate Notice - SAMPLE ONLY

Form used to compute Your Workers' Compensation premiums. Page 2 has rate notice definitions. Sample only.



Form
F225-004-000
 
Request for Manuals from Claims Training

Fillable form to purchase the Workers’ Compensation Adjudicator (WCA), Claims Management (CM), and Policy Manuals (all 3 manuals on 1 CD) the costs will be added up automatically, the total amount enclosed column will be the amount you need to send as payment.



Form
F241-021-000
 
Worker Verification Form

Completed by the injured worker if they are unable to work due to a workplace injury AND their employer is not paying their full wages.

 



Form
F242-052-000

Alt Language(s):
Español
 
Worker Verification Form - Spanish Formulario de Verificación de Empleo

El trabajador lesionado debe completarlo si no puede trabajar debido a una lesión en el lugar de trabajo Y su empleador no le está pagando su salario completo.  



Form
F242-052-999

Alt Language(s):
Inglés
 
Verification of School Enrollment

Used by the student and a school official each quarter to verify school enrollment.



Form
F242-055-000

Alt Language(s):
Español
 
Claim for Pension by Spouse or Children
Used by a spouse or dependents of a deceased worker. The workers' fatal accident or occupational disease incurred in the course of their employment. This application is needed to determine if applicant(s) is/are entitled to a survivor benefit.

Form
F242-056-000

Alt Language(s):
Español
 
Claim for Pension by Spouse or Children -  Reclamo para Beneficios de Pensión Presentado por el Cónyuge, Pareja Doméstica Registrada o los Hijos (Spanish)

Used by a spouse or dependents of a deceased worker. The workers' fatal accident or occupational disease incurred in the course of their employment. This application is needed to determine if applicant(s) is/are entitled to a survivor benefit.



Form
F242-056-999

Alt Language(s):
Inglés
 
Claim for Pension By Dependents
Used by dependents of a deceased worker to file a claim for benefits.

Form
F242-062-000

Alt Language(s):
Español
 
Reclamo para Beneficios de Pensión Presentado por los Dependientes

Used by dependents of a deceased worker to file a claim for benefits.



Form
F242-062-999

Alt Language(s):
Inglés
 
Occupational Disease & Employment History

Injured worker fills this out to document possible occupational disease and to show work history.



Form
F242-071-000

Alt Language(s):
Español
 
Continuación del Historial de Trabajo y de Enfermedad Ocupacional

El trabajador lesionado llena este formulario para documentar una posible enfermedad ocupacional y para mostrar su historia de trabajo.



Form
F242-071-911

Alt Language(s):
Inglés
 
Historial de Trabajo (Enfermedad Ocupacional)

El trabajador lesionado llena este documento para presentar su historia de trabajo.  El formulario de continuación a esta página es F242-071-911.



Form
F242-071-999

Alt Language(s):
Inglés
Español
 
Application to Reopen Claim Due to Worsening Condition

This application is by injured workers and providers to apply to reopen an industrial injury or occupational disease claim due to worsening condition for claims that have been claims 60 days or longer.



Form
F242-079-000

Alt Language(s):
English/Español
Español
 
Beneficios de Compensación para los Trabajadores: Una guía para los Trabajadores Lesionados - English (Workers' Compensation Benefits: A Guide for Injured Workers)

Folleto: Explica los derechos y responsabilidades de los trabajadores bajo la ley de seguro industrial.  Describe beneficios y cómo presentar un reclamo.  Aviso: Anteriormente titulado, Guía de Beneficios del Seguro Industrial para los Trabajadores.  



Publication
F242-104-999

Alt Language(s):
Inglés
 
Address Change Request for Pensioners

Used by the pensioner to notify L&I of a new mailing address. L&I must receive this form by the first day of the month so your monthly payment is received in a timely manner.



Form
F242-107-000

Alt Language(s):
Español
 
Address Change Request for Pensioners - (Spanish) Solicitud para Cambio de Direccion para Pensionados

Used by the pensioner to notify L&I of a new mailing address. L&I must receive this form by the first day of the month so your monthly payment is received in a timely manner.



Form
F242-107-999

Alt Language(s):
Inglés
 
Report of Accident (ROA) Workplace Injury, Accident or Occupational Disease

This form is not available online. If you are an injured worker, ask your medical provider for a copy of this form or you can complete your portion of the Report of Accident (ROA) online at https://secure.Lni.wa.gov/home.

Medical providers can order the ROA and the worker instruction in Spanish from the L&I Warehouse by using the link below.
http://www.Lni.wa.gov/ClaimsIns/Providers/FormPub/ROA/OrderROA.asp



Form
F242-130-000

Alt Language(s):
Español
 
Report of Accident Instructions -- Spanish Instrucciones para el Reporte de Accidente

This document provides instructions in Spanish on how to complete the worker portion only of the Report of Accident (ROA). Please note that the Report of Accident is not available in Spanish. To order these instructions from the L&I Warehouse, please use the link below.

http://www.Lni.wa.gov/ClaimsIns/Providers/FormPub/ROA/OrderROA.asp



Form
F242-130-999

Alt Language(s):
Inglés
 
Declaration of Entitlement for Widow or Widower Benefits Under Industrial Insurance
Used by the widow/widower whose spouse died of a work related injury or accident. This form must be completed, signed, notarized and returned to L&I within 30 days for non interruption of your benefits.

Form
F242-173-111

Alt Language(s):
Español
 
Declaration of Entitlement for Guardian Benefits under Industrial Insurance
Used by a guardian or other person having custody of the minor or disabled children or dependents of a deceased worker to declare their entitlement to receive the pension benefits for those children/dependents in their care and custody.

Form
F242-173-222

Alt Language(s):
Español
 
Declaration of Entitlement for Dependent of Deceased Worker Benefits Under Industrial Insurance
Used by a dependent of a worker whose death was related to an on the job injury or accident. This form must be completed, signed, notarized and returned to L&I within 30 days for non interruption of benefits.

Form
F242-173-333

Alt Language(s):
Español
 
Declaration of Entitlement for Totally Disabled Worker Benefits Under Industrial Insurance
Used by a totally permanently disabled worker. This form must be completed, signed, notarized and returned to L&I within 30 days for non interruption of benefits.

Form
F242-173-444

Alt Language(s):
Español
 
Declaración de Derechos para Viuda(o) bajo el Programa de Compensación y Beneficios para Trabajadores

Used by the widow/widower whose spouse died of a work related injury or accident. This form must be completed, signed, notarized and returned to L&I within 30 days for non interruption of your benefits.



Form
F242-173-911

Alt Language(s):
Inglés
 
Declaración de Derechos para Padres o Tutor Bajo el Programa de Compensación y Beneficios para Trabajadores

Used by a guardian or other person having custody of the minor or disabled children or dependents of a deceased worker to declare their entitlement to receive the pension benefits for those children/dependents in their care and custody.



Form
F242-173-922

Alt Language(s):
Inglés
 
Declaración de Derechos para Dependiente del Trabajador Fallecido Bajo el Programa de Compensación y Beneficios para Trabajadores

Used by a dependent of a worker whose death was related to an on the job injury or accident. This form must be completed, signed, notarized and returned to L&I within 30 days for non interruption of benefits.



Form
F242-173-933

Alt Language(s):
Inglés
 
Declaración de Derechos para los Beneficios de un Trabajador Totalmente Discapacitado Bajo las Leyes del Seguro Industrial

Used by a totally permanently disabled worker. This form must be completed, signed, notarized and returned to L&I within 30 days for non interruption of benefits.



Form
F242-173-944

Alt Language(s):
Inglés
 
Authorization for Deposit of Payments

Used by pensioner to authorize L&I to deposit the pension payment to any designated financial institution.



Form
F242-174-000

Alt Language(s):
English/Español
 
Notice to Employees -- If a Job Injury Occurs/Aviso a los empleados--Si Ocurre una Lesión en el Trabajo (English/Spanish)

Required poster: Outlines the steps a worker should take if a job-related injury or illness occurs. Also briefly describes the benefits available through Washington's workers' compensation system. Note: 'Employers who receive industrial insurance coverage from L&I must display this poster where workers can see it. English and Spanish online versions will print separately.



Poster
F242-191-909
 
How to Protest a Department of Labor and Industries Decision (English/Spanish) Cómo Protestar una Decisión en su Reclamo del Departamento de Labor e Industrias

Fact sheet: Explains how an injured worker can protest decisions on his/her claim and gives deadlines for taking action.



Publication
F242-363-909
 
Statement for Compound Prescription

Bill form for use by pharmacies and home infusion companies to submit compound drug charges. This form is for drug charges only and is filled out by the pharmacist.



Form
F245-010-000
 
Statement for Retraining and Job Modification Services

Bill form for providers that bill the department for claim-related retraining and job modification services. See the General Provider Billing Manual (248-100-000) for information on completing this form.



Form
F245-030-000
 
Transfer of Care Card

Used by injured worker to notify claim manager and request authorization to transfer care to a different doctor. Do it online! Use the online Transfer of Care



Form
F245-037-000

Alt Language(s):
Español
 
Transfer of Care Card (Spanish) Tarjeta para Transferencia de Caso

Used by injured worker to notify claim manager and request authorization to transfer care to a different doctor.



Form
F245-037-999

Alt Language(s):
Inglés
 
Provider Account Application - Independent Medical Examiner (IME)

In order to do independent medical exams a provider must obtain a provider account number with L&I. This packet includes the application and agreement with instructions, IME Provider Exam sites form (F245-047-000) and Request for Taxpayer ID and Certification - Form W-9 (F248-036-000) (10 pages). If you have questions, please email balk235@lni.wa.gov or call 360-902-6815.



Form
F245-046-000
 
Independent Medical Examination (IME) Provider Exam Sites

List the locations where the doctor does independent medical exams on a regular basis.



Form
F245-047-000
 
Approved Independent Medical Examiner (IME) Update
To update or correct the IME's contact, availability, qualificaitons and/or exam sites.

Form
F245-051-000
 
Submission of Provider Credentials for Interpretive Services

Used to apply as a interpretive service provider and to show what language(s) you hold credentials for. F248-011-000 Provider Application and Notice is added to this form.



Form
F245-055-000
 
Interpretive Services Appointment Record

This form is used when an interpreter is appointed to interpret for an injured worker during their medical visits.

When ordering, there is a limit of 4 pads, or 100 copies total. Fax your request to the L&I Warehouse at 360-902-4525 or email whsemail@Lni.wa.gov   Include the following in your request: Your name, mailing address, and telephone number and form number F245-056-000.



Form
F245-056-000
 
Independent Medical Exam Template
Template used by a doctor during an independent medical exam.

Form
F245-058-000
 
Statement for Miscellaneous Services

This bill form is used by providers and injured workers to bill the department for services such as dental care; glasses; medical equipment; nursing home services; interpreter services; services workers pay for out of pocket; and other services. Information on how to bill the department can be found in the General Provider Billing Manual [F248-100-000].

 



Form
F245-072-000

Alt Language(s):
Español
 
Statement for Pharmacy Services

Bill form for prescription charges. May be used by a pharmacy to submit drug charges, or by a worker to request reimbursement for prescriptions paid out of pocket. See the General Provider Billing Manual (F248-100-000) for information on completing this form.



Form
F245-100-000
 
CMS 1500 (formerly L&I Health Insurance Claim form)
Used by providers to be reimbursed for services. It is NOT for use by injured workers to submit a claim to L&I.

Form
F245-127-000
 
Travel Reimbursement Request

Bill form for use by workers to request reimbursement for authorized travel expenses.



Form
F245-145-000

Alt Language(s):
Español
 
Travel Reimbursement Request - (Spanish) Solicitud para el Reembolso de Gastos de Viaje

Injured workers use this form to request reimbursement for travel expenses used to receive treatment, retraining and/or vocational services.



Form
F245-145-999

Alt Language(s):
Inglés
 
Provider's Request for Adjustment

Providers use this to report total overpayment, partial overpayment and/or underpayment by L&I.



Form
F245-183-000
 
Your Independent Medical Exam

Pamphlet/booklet: Answers the most common questions about independent medical exams and when and why an injured worker may be required to receive one. Includes the "IME Travel & Wage Reimbursement Request" form.



Form
F245-224-000

Alt Language(s):
Español
 
Su Examen Médico Independiente

Pamphlet/booklet: Answers the most common questions about independent medical exams and when and why an injured worker may be required to receive one. Includes the "IME Travel & Wage Reimbursement Request" form.



Form
F245-224-999

Alt Language(s):
Inglés
 
Job Modification Assistance Application

For use by an vocational counselor, employer, etc. to request modification for the injured workers job. This may involve tools and equipment that is purchased through L&I.



Form
F245-346-000
 
Pre-Job Accommodation Assistance Application

For use by a therapist or vocational provider to request job modification for an injured worker before the injured workers is employed, possibly in a retraining program. This may involve tools and equipment that is purchased through L&I.



Form
F245-350-000
 
Vocational Training Plan Ownership Agreement for Tools and Equipment

Injured worker agrees to the ownership terms of the tools and/or equipment purchased as part of their training plan by L&I.



Form
F245-351-000
 
Provider Credentialing Change Form

Providers use this form to notify L&I of a change of their business address, billing address and account termination. Also has info on how to notify L&I on a tax ID (EIN) number change, tax ID address change and/or name change.



Form
F245-365-000
 
UB04 HCFA 1450

Used by hospitals to bill L&I for inpatient/outpatient services. This version includes NPI number.



Form
F245-367-000
 
Non-Network Provider Application

Includes the F248-036-000 Statewide Payee Registration and W-9 form. For providers to complete that do not want to become a Labor and Industries network provider, or for a specialty that L&I is not accepting network applications for at this time. If you are applying to be a Labor and Industries network provider, please complete application process at www.ProviderNetwork.Lni.wa.gov



Form
F248-011-000
 
Electronic Billing Authorization

To authorize L&I to accept electronically submitted bills for services provided to injured workers (2 pages).



Form
F248-031-000
 
Statewide Payee Registration and W-9 Form

Use this form to submit your taxpayer ID number. Note: Register now for direct deposit.



Form
F248-036-000
 
Hotline Tips for Medical Services Providers
Fact sheet: Provides tips to help medical service providers quickly obtain answers to claims and billing questions. Introduces L&I's Provider Hotline, Interactive Voice Response Message System and online Claim & Account Center.

Publication
F248-040-000
 
Occupational or Physical Therapy Treatment Authorization Fax Request

Used by a therapy provider/clinic to request authorization for outpatient occupational or physical therapy services for L&I claims.



Form
F248-055-000
 
Payroll Service Provider - Quarterly Reporting Bulk Filing Enrollment Form

Used by payroll services to enroll and register with L&I for downloading/uploading account information from the Express Filing site using an electronic list (text file) of accounts.



Form
F248-343-000
 
Third Party Recovery Worksheet

Used by third party attorneys to calculate distribution of proposed settlements in third party claims.



Form
F249-006-111
 
Injured by a third party?  

Brochure: Summarizes the legal rights and options an injured worker has if a third-party action pertains to his/her workers' compensation claim. Includes the Third Party Election Form that must be completed by the worker. Note: The form must be printed, signed and mailed.



Form
F249-008-000

Alt Language(s):
Español
 
Application for Inclusion on List of Eligible Attorneys
Used by attorneys to be included on the Workers' Compensation Special Assistant Attorney General Program eligible list for Third Party claims.

Form
F249-017-000
 
Individual Retrospective Rating Plan Agreement
Used by employers to set up an agreement between them and L&I authorizing their participation in retrospective rating.

Form
F250-003-000
 
Application for Group Retrospective Rating
Used by organizations to set up an agreement with L&I authorizing their participation in retrospective rating.

Form
F250-004-000
 
Application for Group Membership & Authorization for Release of Insurance Data
Used by employers who want to join a retrospective rating group; also, to authorize Labor & Industries to release the employers' insurance data to the retrospective rating group they want to join.

Form
F250-016-000
 
Medical Examiners' Handbook

Book: A publication for independent medical examiners, attending doctors and consultants, this document contains guidelines, sample reports and billing procedures for preparing and conducting impairment ratings and independent medical exams in Washington's workers' compensation system. Beginning July 1, 2012, free Category I CME credits are available for completing the self-assessment associated with this handbook. Go to www.Imes.Lni.wa.gov and click on Medical Examiners Handbook for information on the exam. L&I and the authors have no financial interest or other relationship with the manufacturer(s) of any commercial product(s) and/or provider of commercial services discussed in this document.



Publication
F252-001-000
 
Doctor's Worksheet for Rating Dorso-Lumbar & Lumbo-Sacral Impairment
This worksheet is to help the attending physician perform impairment rating on their patients with permanent partial disability of the Dorso-Lumbar or Lumbo-Sacral spine.

Form
F252-006-000
 
Hearing Impairment Calculation Worksheet
Used by the attending doctor to determine hearing loss.

Form
F252-007-000
 
Medical Device Review Request

This form is so L&I's Office of the Medical Director can evaluate medical device(s) that the attending physican wants to use to treat an injured worker.



Form
F252-013-000
 
Vocational Providers Application and Notice

Used to obtain a vocational provider account number with L&I. This form includes a copy of F248-036-000 "Request for Taxpayer ID number and Certification". (12 pages) CURRENT EXISTING VOCATIONAL PROVIDER FIRMS THAT ARE ALREADY REGISTERED WITH L&I USE THIS FORM AND W-9.



Form
F252-017-000
 
Individual Vocational Provider Account Change Form

To change an individual's (service provider's) name, add or delete referral categories, update certifications, leaving a firm, intern supervisor changes, and/or adding or deleting a branch for referrals.



Form
F252-021-000
 
Firm Vocational Provider Account Change

To change a firm's (payee provider's) branch address within the same service location, contact info, tax info, adding or deleting designee for your firm.



Form
F252-022-000
 
Vocational Closing Report Routing Sheet

Routing slip that accompanies the Vocational Services Closing Cover Sheet (F252-028-000) which is used to close vocational services to an injured worker.



Form
F252-027-000
 
Vocational Services Closing Cover Sheet

Used to close vocational services of an injured worker. This form is attached to Vocational Closing Report Routing Sheets F280-013-000, F280-014-000 or F252-027-000.



Form
F252-028-000
 
Sample Self-Employment Agreement

Sample of a letter a return to work person would use to assist L&I in determining whether services or funds should be authorized to assist them in becoming self-employed.



Form
F252-032-000
 
Employer's Job Description

Used by employer of record to prepare a written job description for a light-duty job, transitional, modified duty job, or alternative job when an injured worker is unable to work due to an industrial injury or occupational disease. The form includes a description of the job tasks, machinery, tools, equipment and personal protective equipment used, and the physical demands of the job. After completing the employer's job description form, the employer gives it to the injured worker's doctor for review and approval.



Form
F252-040-000
 
Sample Format for Vocational Testing Report

Used by vocational counselors to test an injuried worker's skills and abilities.



Form
F252-051-000
 
Sample Format for Vocational Evaluation Testing Plan

Used by vocational counselors to evaluate the testing plan of the injuried worker.



Form
F252-052-000
 
Industrial Insurance Discrimination Complaint
Employees who believe they have been discriminated against by their employer use this form to file a complaint.

Form
F262-009-000

Alt Language(s):
Español
 
Queja por Discriminación

Used by employees who believe they have been discriminated against by their employer may use this form to file a complaint.



Form
F262-009-999

Alt Language(s):
Inglés
 
Occupational Disease Employment History Hearing Loss
Used by injured worker who has filed an occupational hearing loss claim to report their employment history and the nature of the noise exposure at each job. F262-013-111 is the continuation sheet.

Form
F262-013-000

Alt Language(s):
Español
 
Occupational Disease Employment History Hearing Loss (Continuation)
Used by injured worker who has filed an occupational hearing loss claim to report their employment history and the nature of the noise exposure at each job. This form is a continuation of form F262-013-000.

Form
F262-013-111

Alt Language(s):
Español
 
Occupational Hearing Loss Questionnaire
Used by injured worker who has filed an occupational hearing loss claim to provide more specific information regarding how the hearing loss occurred. This is requested by the Claim Manager and sent to the Injured Worker.

Form
F262-016-000

Alt Language(s):
Español
 
Cuestionario Sobre la Pérdida del Sentido Auditivo en el Trabajo

Used by injured worker who has filed an occupational hearing loss claim to provide more specific information regarding how the hearing loss occurred. This is requested by the Claim Manager and sent to the Injured Worker.



Form
F262-016-999

Alt Language(s):
Inglés
 
Intent to Hire Preferred Worker
Used by employers when hiring a preferred worker. This form must be received within 60 days of the hiring and the Preferred Worker Employer's Job Description (F280-022-000) form must be attached.

Form
F280-010-000
 
Intent to Hire Preferred Worker with Developmental Disabilities
Used by employers rehiring developmentally disabled workers after an industrial injury. This form requests preferred worker status and shows the physical demands of the work to be performed by the worker. The Preferred Worker Employer's Job Description (F280-022-000) should be attached.

Form
F280-011-000
 
Preferred Worker Employers Job Decsription
Used by the employer to describe the job for the preferred worker. This form is reviewed by a vocational services consultant to ensure that the offered job is consistent with the worker's medical restrictions.

Form
F280-022-000
 
Request for Preferred Workers Status

Used by vocational providers to apply for preferred worker status on behalf of an industrially injured worker.



Form
F280-023-000
 
Chemical Hazard Communication: Helpful information for employers
Book: Provides employers a checklist on the requirements of the chemical hazard communication rule. Contains an extensive question-and-answer section and information on starting an employee-training program.

Publication
F413-012-000

Alt Language(s):
中国的
한국의
Español
Việt
 
Your Body, Your Job: Preventing Carpal Tunnel Syndrome and Other Upper Extremity Musculoskeletal Disorders
Pamphlet/booklet: Reviews the symptoms and risk factors for carpal tunnel syndrome and several other musculoskeletal disorders that affect the shoulder, arm and elbow. Discusses prevention approaches and where to get more information.

Publication
F413-024-000

Alt Language(s):
Español
 
Su cuerpo, su empleo: Prevención del Síndrome del Túnel Carpiano y otras lesiones músculo esqueléticas...

Pamphlet/booklet: Reviews the symptoms and risk factors for carpal tunnel syndrome and several other musculoskeletal disorders that affect the shoulder, arm and elbow. Discusses prevention approaches and where to get more information.



Publication
F413-024-999

Alt Language(s):
Inglés
 
Asbestos Abatement Project Notice of Intent and L&I DOSH Asbestos Program

Notice is not required for any asbestos project involving less than forty-eight (48) square feet of surface area, or less than ten (10) linear feet of pipe unless the surface area of the pipe is greater than forty-eight (48) square feet. Get instructions to complete the form.



Form
F413-025-000
 
Working Safely with Asbestos in Brake and Clutch Linings
Pamphlet/booklet: Reviews the health hazards of asbestos exposure, use of asbestos in brake and clutch linings, employer's responsibilities, how employees can protect themselves, employee rights, and where to get help with waste management.

Poster
F413-049-000
 
Cholinesterase Blood Testing Choice

Use this form to say whether or not you choose to have the Cholinesterase blood tests performed.



Form
F413-064-000

Alt Language(s):
Español
Español
 
Elección para Prueba de Sangre de Colinesterasa

Use this form to say whether or not you choose to have the Cholinesterase blood tests performed.



Form
F413-064-999

Alt Language(s):
Inglés
Inglés
 
Variance Application - IND S&H

Use this form to apply for a variance for an allowed deviation from a specific safety or health standard when an employer substitutes measures which afford an equal degree of safety.



Form
F414-021-000
 
Workplace Safety and Health Rules and Guides

CD: Contains workplace safety and health rules for Washington State and links to policies and related laws. Also contains guides covering accident prevention programs (APP) and personal protective equipment (PPE). Note: Order CD or view rules online.



CD
F414-074-034
 
Safety and Health Discrimination Complaint

Use this form to file a complaint when you feel you've been discriminated against or discharged for reporting a workplace safety hazard.



Form
F416-011-000

Alt Language(s):
Español
 
Safety and Health Discriminaiton Complaint - (Spanish) Queja de Discriminación de la División de Seguridad Y Salud Ocupacional

Si Usted piensa que ha sido discriminado o despedido por reportar los peligros existentes en su lugar de trabajo, utilice este formulario para presentar una queja.



Form
F416-011-999

Alt Language(s):
Inglés
 
Statement

This form is predominately used in non-accident related types of inspections. Used to obtain statements from employees or other individuals whenever it is determined that it would be useful to adequately document an apparent violation.



Form
F416-016-000
 
Application for Charter Boat Operators License

Use this form to apply for an operators license of a charter vessel.



Form
F416-034-000
 
Physical Exam - Charter Boat Operators License

This form is used by applicants applying for a charter boat operators license to have completed by a physician for an operators license



Form
F416-056-000
 
Job Safety and Health Law - Spanish Ley de Seguridad y Salud en el Trabajo (English/Spanish)

Required poster: Describes important parts of the Washington Industrial Safety and Health Act (WISHA), which provides for job safety and health of Washington employees. Note: Employers in Washington State must display this poster where workers can see it. When ordering the printed version, you will receive one 22" X 17" poster that includes both languages.

Please order from L&I or print on 11" x 17" paper.

Get poster printing tips.



Poster
F416-081-909
 
Application for Permit to Operate Radio System in Designated Area

This form is used by the logging industry to apply for a permit to operate a radio signal system. What you type in the top form appears in the bottom one, so you have a copy.



Form
F416-087-000
 
A Guide to Workplace Safety and Health in Washington State

Pamphlet/booklet: Provides an overview of the Washington Industrial Safety and Health Act (WISHA), worker and employer rights and responsibilities, enforcement of WISHA rules, and consultation and education services L&I provides. Previously titled A Guide to WISHA



Publication
F416-132-000

Alt Language(s):
Español
 
Logging Emergency Medical Plan (Logging Safety and Health Meetings)

Use this two part form for employers to record work locations and emergency rescue info and for holding safety meetings for each new jobsite



Form
F417-014-000
 
Supervisor's Report of an Accident

Supervisors use this form to document information from an accident or injury.



Form
F417-048-000
 
Quick Tips for Lifting/Consejos Breves para Levantar Cargas (English/Spanish)

Fact sheet: Provides 10 tips for safer lifting. Contains illustrations.



Publication
F417-055-909
 
Competent Person Evaluation - Fall Restraint & Fall Arrest

The employer uses this checklist to determine the person they have designated as a competent person is competent within the description and intent of the fall restraint and fall arrest standard.



Form
F417-102-000
 
Competent Person Evaluation - Excavation & Trenching

The employer uses this checklist to determine the person they have designated as a competent person is competent within the description and intent of the excavation and trenching standards.



Form
F417-104-000
 
Fall Protection Work Plan Requirements

This booklet defines the work plan requirements you must meet for fall protection.



Form
F417-107-000
 
Lessons for Lifting & Moving Materials
Book: Identifies work areas, tasks and procedures that place employees at risk of injury. Describes and illustrates methods that help reduce the risk of injury.

Publication
F417-129-000
 
Office Ergonomics: Practical solutions for a safer workplace
Book: Provides information and tools to analyze office jobs, find problems and develop ergonomic solutions.

Publication
F417-133-000
 
Workplace Violence: Awareness and Prevention for Employers and Employees
Book: Describes four types of workplace violence, outlines steps to minimize and prevent violent acts, and discusses potential risk factors and prevention techniques.

Publication
F417-140-000
 
Safety and Health Discrimination in the Workplace (English/Spanish)/ Discriminación de seguridad y salud en el lugar de trabajo

Poster: Employees have the right to report concerns about safety and health in their workplace. This poster describes "protected activities" under the Washington Industrial Safety and Health Act (WISHA) and explains what an employee should do if he/she has been punished or fired for exercising these rights. Get poster printing tips.



Poster
F417-188-909
 
Lumber Handling in Sawmills

Book: Developed by mill workers, mill managers and L&I, this manual describes the risks of musculoskeletal injury in lumber-handling jobs. Identifies controls to reduce hazards,increase efficiency and reduce injuries.



Manual
F417-196-000
 
Reservation Form Safety and Health Video Library

Use this form to make reservations of safety and health videos. There is both a fillable MS Word form that you can email in, and a fillable PDF that you can fill and print.



Form
F417-206-000
 
Personal Protective Equipment (PPE) Guide
Book: This guide helps employers comply with the WISHA Personal Protective Equipment rules. It covers general personal protective equipment and PPE requirements used to protect the head, eyes and face, hand and arm, foot and leg, and body (torso) in most work environments.

Publication
F417-207-000
 
Fall Protection: Responding to Emergencies
Book: This guide is for employers and for employees who work from exposed, elevated surfaces. It covers the following: what to do to prevent fall-related emergencies and how to respond promptly if a fall-related emergency occurs. Includes illustrations of aided-rescue equipment systems.

Publication
F417-208-000
 
Keep Your Employees Safe and Working

Pamphlet/booklet: Describes the benefits of free employer consultations offered by L&I's Division of Occupational Safety and Health (DOSH). These services include on-site safety and/or industrial hygiene consultations, ergonomics assistance and risk management advice.



Publication
F417-209-000

Alt Language(s):
Español
 
Keep Your Employees Safe and Working - Spanish (Mantenga a sus empleados seguros y trabajando)

Pamphlet/booklet: Describes the benefits of free employer consultations offered by L&I's Division of Occupational Safety and Health (DOSH). These services include on-site safety and/or industrial hygiene consultations, ergonomics assistance and risk management advice.



Publication
F417-209-999

Alt Language(s):
Inglés
 
Jorge's New Job: Cholinesterase Testing in Washington State - Spanish Un Nuevo Trabajo para Jorge(English/Spanish)

Pamphlet/booklet: Uses a story format with dialogue and photographs to explain the hazards of cholinesterase-inhibiting pesticides, the state's monitoring program and the importance of using proper safety equipment when working with pesticides.



Publication
F417-213-909
 
Protect Yourself and Your Family from Lead Poisoning
Pamphlet/booklet: Explains the risks of lead exposure for workers who work on outdoor steel structures, and harmful effects on workers and their families. It includes a poster about the importance of safe work practices and procedures.

Publication
F417-214-000
 
Application for Copies of Citation and Notice

Used by an employee to apply for copies of citation and notices issued to their employer.



Form
F418-023-000
 
Alleged Safety Or Health Hazards (DOSH Complaint Form)

Employees use this form to report work place conditions which jeopardize workers safety and health.



Form
F418-052-000

Alt Language(s):
Español
 
Alleged Safety Or Health Hazards (DOSH Complaint Form) Spanish - Presuntos Riesgos de Salud y Seguridad (Formulario de Queja de DOSH)

Employees use this complaint form to report work place conditions which jeopardize workers safety and health.



Form
F418-052-999

Alt Language(s):
Inglés
 
Stay at Work Wage Reimbursement Application for Employers

Employer of record can request reimbursement for wages paid to an injured worker during light duty or transitional work. After completing the form, the employer submits it, along with supporting documentation, to the Stay at Work program for review and approval. For expense reimbursements see F243-003-000.



Form
F243-001-000
 
Application for Amusement Ride or Air Supported Structure Operating Permit

To apply for a decal for an amusement ride or air supported structure.



Form
F500-010-000
 
Stay at Work Expense Reimbursement Application for Employers Tools, Clothing, Training.

Employer of record can request reimbursement for tools, clothing, or training expenses required to enable an injured worker to return to light duty or transitional work. After completing the form, the employer submits it, along with supporting documentation, to the Stay at Work program for review and approval. For wage reimbursements see F243-001-000.



Form
F243-003-000
 
Application for Electrical Contractors License

Application used to get an electrical contractors license



Form
F500-018-000
 
Employer's Return-to-Work Guide

Pamphlet/booklet: Explains the benefits of 'return to work' from the employer's perspective, describes RTW options, and provides resource and contact information.



Publication
F200-003-000
 
Electrical/Telecommunications Contractor's Bond to the State of WA
Used to show proof of a bond in the State of Washington.

Form
F500-019-000
 





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