Stand-alone document that can be used with all Ability to Work Assessment outcomes.

Used by rehabilitation providers to document in a vocational assessment that a worker needs further services.

This document provides the facts necessary to make an informed decision regarding vocational retraining benefits and explains the responsibilities you and your vocational counselor (VRC) have.

This document provides the facts necessary to make an informed decision regarding vocational retraining benefits and explains the responsibilities you and your vocational counselor (VRC) have. For OJT retraining plans, please refer to form F280-029-000.

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

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.

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.

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

State fund workers who have selected Option 2 and closed their claim can use this form to apply for access to their Option 2 training funds. To seek reimbursement, use form F245-030-000 Statement for Retraining and Job Modification Services.

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.

Fact sheet: Includes information regarding the benefits of Preferred Worker certification, answers to questions frequently asked by workers, phone and website contacts.

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

Used by self-insured employers and their representatives to report to L&I an injured worker's eligibility for vocational services or ability to work. This replaces F207-121-000 Employability Assessment Report (EAR).

Used by the provider or supplier for reimbursement of the following services - dental, glasses, home health, nursing home serivces, medical equipment, prosthetics-orthotics, transportation, vocational, retraining and other.

To record the training costs. For use only with plans approved after 1/1/2008.

To record the costs for transportation. For use only with plans approved after 1/1/2008.

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

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

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.

Employer Application for Special Certificate to Employ A Vocationally Handicapped Worker at at Subprevailing

Booklet: Explains the basics of the assessment phase of vocational services to injured workers. L&I sends this booklet to injured workers when they are referred for assessment services.

Booklet: Explains the basics of the assessment phase of vocational services to injured workers. L&I sends this booklet to injured workers when they are referred for assessment services.

Used by only private sector vocational rehabilitation providers to document vocational assessment to determine if a worker is employable based upon transferable skills or needs further vocational services such as retraining.

For use internally by L&I Vocational Service Specialists (VSSs) to determine if all required components are included in the submitted assessment. Can be used by VRCs as a tool. DO NOT SUBMIT TO L&I.

Routing slip that accompanies the Vocational Services Closing Cover Sheet (F252-028-000) which is used to close vocational services to an injured worker only if you are recommending Plan Development. For all other closing reports, use Vocational Closing Report Routing Sheet (F252-027-000).

Booklet: Explains the basics of the plan implementation phase of vocational services to injured workers. L&I sends this booklet to injured workers once the vocational plan they submitted is approved. Information about continuing with the vocational plan or selecting Option 2 to decline retraining is included.

Booklet: Explains the basics of the plan implementation phase of vocational services to injured workers. L&I sends this booklet to injured workers once the vocational plan they submitted is approved. Information about continuing with the vocational plan or selecting Option 2 to decline retraining is included.

Completion of this form is not a guarantee of benefits. Payment of benefits will be decided by your claim manager.

Completion of this form is not a guarantee of benefits. Payment of benefits will be decided by your claim manager.

Completion of this form is not a guarantee of benefits. Payment of benefits will be decided by your claim manager.

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.

To record the costs for housing and board. For use only with plans approved after 1/1/2008.

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.

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.

Used by vocational rehabilitation counselors (VRCs) to document the physical demands of jobs.

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.

Used to order L&I medical forms.

Used by non-accredited or unlicensed training providers in order to be reviewed for approval to become a training provider for Washington injured workers. Must be submitted with the Provider Account Application (F248-011-000).

OJT Accountability Agreement in Spanish

VRCs can use this form to request information on a specific on -the -job (OJT) training opportunity listed on L&I's website, or to recommend an OJT training opportunity.

This form is for OJT training plans, and must be signed by the worker and VRC then sent in along with your training plan to L&I for approval. For non-OJT retraining plans, please refer to form F280-016-000.

On-The-Job Training (OJT) Worksheet for Vocational Providers

State fund workers who have selected Option 2 and closed their claim can use this form to apply for access to their Option 2 training funds. To seek reimbursement, use form F245-030-000 Statement for Retraining and Job Modification Services.

Booklet: Explains what happens when an individual selects "Option 2" and choose not to participate in the approved training plan.

For use internally by L&I Vocational Service Specialists (VSSs) to determine if all required components are included in the submitted plan. Can be used by VRCs as a tool. DO NOT SUBMIT TO L&I.

Routing slip that accompanies the Vocational Services Closing Cover Sheet (F252-028-000) which is used to close vocational services to an injured worker only if you are recommending Plan Approval. For all other closing reports, use Vocational Closing Report Routing Sheet (F252-027-000).

Booklet: Explains the basics of the plan development phase of vocational services to injured workers. L&I sends this booklet to injured workers when they are referred for plan development services. The assigned vocational rehabilitation counselor is required to review this booklet with the worker at their initial face-to-face meeting.

Booklet: Explains the basics of the plan development phase of vocational services to injured workers. L&I send this booklet to injured workers when they are referred for plan development services. The assigned vocational rehabilitation counselor is required to review this booklet with the worker at their initial face-to-face meeting.

To record the work plan time. For use only with plans approved after 1/1/2008.

Fact sheet: Includes information regarding the benefits of Perferred Worker certification, answers to questions frequently asked by workers, phone and website contacts.

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.

Complete this application and the StateWide Payee W-9 if you are applying for a firm Provider Number with L&I.

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

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.

Used by self-insured employers, their representatives, and vocational counselors to summarize the outcome of a vocational rehabilitation plan when submitting the closing report.

If you are considered a victim of crime, use this form to track your travel expenses for medical, retraining or vocational services or for an independent medical exam. You should have approval from your claim manager before you travel.

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

Vocational Questionnaire/Work History for use by Vocational Providers serving injured workers.

Vocational Questionnaire/Work History for use by Vocational Providers serving injured workers

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.

This form is for recruiting private sector vocational counselors to be on the Vocational Technical Stakeholder Group (VTSG). The form is made available on the department’s vocational website when recruiting for new members to assist the department in addressing vocational issues and formulating policy. Prospective applicants are expected to download, sign, and return the form to PSRS for consideration.

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