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Accountability Agreement - (Spanish) Acuerdo de Responsabilidad

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.



Form
F280-016-999



Alt Language(s):
Inglés
 
Accountability Agreement - (Spanish) Acuerdo de Responsabilidad

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.



Form
F280-016-999



Alt Language(s):
Inglés
 
Accountability Agreement - (Spanish) Acuerdo de Responsabilidad

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.



Form
F280-016-999



Alt Language(s):
Inglés
 
Application for LEP Vocational English/Spanish Solicitud para Compensación por Reducción de Ingresos (Vocacional)

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



Form
F242-209-909



Alt Language(s):
Inglés
Español
 
Application for Loss of Earning Power (LEP) - Vocational

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



Form
F242-209-000



Alt Language(s):
English/Español
Español
 
Assessing Your Ability to Work: Your Rights and Responsibilities -- Spanish (Evaluando su Capacidad para Trabajar: Sus Derechos y Responsabilidades, Servicios de Rehabilitación Vocacional)

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.



Publication
F280-017-999



Alt Language(s):
Inglés
 
Assessment Closing Report

Used by only private sector vocational rehabilitation providers to document vocational assessment to determine if a worker is employable based upon transferable skills.



Form
F252-029-000


 
Assessment Closing Report

Used by only private sector vocational rehabilitation providers to document vocational assessment to determine if a worker is employable based upon transferable skills.



Form
F252-029-000


 
Assessment Eligible Quality Assurance Review Form

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.



Form
F280-008-000


 
Assessment Eligible Quality Assurance Review Form

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.



Form
F280-008-000


 
Department of Labor and Industries Home Modification Acknowledgement of Responsibilities

Used by both workers and bidding contractors to read, sign and submit to L&I to verify that they have read, understand and accept their respective responsibilities in the home modification process.



Form
F247-003-000



Alt Language(s):
Español
 
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


 
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


 
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


 
F242-209-999 application for LEP - Voc Spanish -  Aplicación para Compensación por Reducción de Ingresos (Vocacional)

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



Form
F242-209-999



Alt Language(s):
Inglés
English/Español
 
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


 
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


 
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


 
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


 
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


 
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


 
Job Analysis Summary

Summary that goes on top of a job analysis.  Gives the physician a snapshot of the physical demands of a job.



Form
F252-101-000


 
Job Analysis

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



Form
F252-072-000


 
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



Alt Language(s):
Español
 
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



Alt Language(s):
Español
 
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



Alt Language(s):
Español
 
Non-accredited or Unlicensed Training Provider Application Supplemental Requirements

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).



Form
F280-045-000


 
Non-accredited or Unlicensed Training Provider Application Supplemental Requirements

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).



Form
F280-045-000


 
OJT Information Request and Recommendation form

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.



Form
F280-032-000


 
OJT Information Request and Recommendation form

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.



Form
F280-032-000


 
On the Job Training Accountability Agreement

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.



Form
F280-029-000



Alt Language(s):
Español
 
On the Job Training Accountability Agreement

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.



Form
F280-029-000



Alt Language(s):
Español
 
On the Job Training Accountability Agreement

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.



Form
F280-029-000



Alt Language(s):
Español
 
On the Job Training Accountability Agreement

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.



Form
F280-029-000



Alt Language(s):
Español
 
On-The-Job Training (OJT) Agreement for Vocational Providers

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



Form
F280-039-000


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

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



Form
F280-039-000


 
Option 2 Vocational Benefits Training Enrollment Application and Verification

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.



Form
F280-024-000



Alt Language(s):
English/Español
 
Option 2 Vocational Benefits Training Enrollment Application and Verification

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.



Form
F280-024-000



Alt Language(s):
English/Español
 
Option 2 Vocational Benefits Training Enrollment Application/Aplicación y Verificación del Registro (English/Spanish)

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.



Form
F280-024-909



Alt Language(s):
Inglés
 
Option 2 Vocational Benefits Training Enrollment Application/Aplicación y Verificación del Registro (English/Spanish)

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.



Form
F280-024-909



Alt Language(s):
Inglés
 
Plan Development Quality Assurance Review Form

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.



Form
F280-007-000


 
Plan Development Quality Assurance Review Form

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.



Form
F280-007-000


 
Plan Development: What Are My Rights & Responsibilities -- Spanish (Plan de Desarrollo: ¿Cuáles son mis Derechos y Responsabilidades? Servicios de Rehabilitación Vocacional)

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.



Publication
F280-018-999



Alt Language(s):
Inglés
 
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



Alt Language(s):
Español
 
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



Alt Language(s):
Español
 
Provider Application and Notice for new firms

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



Form
F252-088-000


 
Provider Application and Notice for new firms

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



Form
F252-088-000


 
Provider Application and Notice for new firms

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



Form
F252-088-000


 
Referral for WorkSource Services from Private Vocational Provider

Used by private Vocational Providers to refer injured workers to WorkSource



Form
F280-046-000


 
Referral for WorkSource Services from Private Vocational Provider

Used by private Vocational Providers to refer injured workers to WorkSource



Form
F280-046-000


 
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


 
Sample Format for Vocational Evaluation Testing Plan

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



Form
F252-052-000


 
Sample Format for Vocational Evaluation Testing Plan

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



Form
F252-052-000


 
Sample Format for Vocational Evaluation Testing Plan

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



Form
F252-052-000


 
Sample Format for Vocational Evaluation Testing Plan

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



Form
F252-052-000


 
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 Testing Report

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



Form
F252-051-000


 
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 Testing Report

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



Form
F252-051-000


 
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


 
Self-Insurance Vocational Reporting Form

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).



Form
F207-190-000


 
Training Plan Cost Encumbrance

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



Form
F245-374-000


 
Training Plan Cost Encumbrance

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



Form
F245-374-000


 
Transportation Cost Encumbrance

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



Form
F245-375-000


 
Transportation Cost Encumbrance

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



Form
F245-375-000


 
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

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



Form
F245-145-000



Alt Language(s):
Español
 
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 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 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


 
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


 
Vocational Questionnaire/Work History - Spansih CUESTIONARIO VOCACIONAL/HISTORIA DE TRABAJO

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



Form
F280-038-999


 
Vocational Questionnaire/Work History - Spansih CUESTIONARIO VOCACIONAL/HISTORIA DE TRABAJO

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



Form
F280-038-999


 
Vocational Questionnaire/Work History - Spansih CUESTIONARIO VOCACIONAL/HISTORIA DE TRABAJO

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



Form
F280-038-999


 
Vocational Questionnaire/Work History

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



Form
F280-038-000



Alt Language(s):
Español
 
Vocational Questionnaire/Work History

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



Form
F280-038-000



Alt Language(s):
Español
 
Vocational Questionnaire/Work History

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



Form
F280-038-000



Alt Language(s):
Español
 
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


 
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


 
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


 
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



Alt Language(s):
Español
 
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



Alt Language(s):
Español
 
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



Alt Language(s):
Español
 
Assessing Your Ability to Work: Your Rights and Responsibilities
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.

Publication
F280-017-000



Alt Language(s):
Español
 
Assessing Your Ability to Work: Your Rights and Responsibilities
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.

Publication
F280-017-000



Alt Language(s):
Español
 
Assessing Your Ability to Work: Your Rights and Responsibilities
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.

Publication
F280-017-000



Alt Language(s):
Español
 
Assessing Your Ability to Work: Your Rights and Responsibilities
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.

Publication
F280-017-000



Alt Language(s):
Español
 
Carrying Out Your Vocational Plan: Your Rights and Responsibilities During Plan Implementation
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.

Publication
F280-019-000



Alt Language(s):
Español
 
Carrying Out Your Vocational Plan: Your Rights and Responsibilities During Plan Implementation
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.

Publication
F280-019-000



Alt Language(s):
Español
 
Carrying Out your Vocational Plan: Your Rights and Responsibilities During Plan Implementation -- Spanish (Llevando a cabo su Plan vocacional: Sus derechos y responsabilidades durante el Plan de Implementación, Servicios de rehabilitación vocacional)
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.

Publication
F280-019-999



Alt Language(s):
Inglés
 
Carrying Out your Vocational Plan: Your Rights and Responsibilities During Plan Implementation -- Spanish (Llevando a cabo su Plan vocacional: Sus derechos y responsabilidades durante el Plan de Implementación, Servicios de rehabilitación vocacional)
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.

Publication
F280-019-999



Alt Language(s):
Inglés
 
Carrying Out your Vocational Plan: Your Rights and Responsibilities During Plan Implementation -- Spanish (Llevando a cabo su Plan vocacional: Sus derechos y responsabilidades durante el Plan de Implementación, Servicios de rehabilitación vocacional)
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.

Publication
F280-019-999



Alt Language(s):
Inglés
 
Housing and Board Cost Encumbrance
To record the costs for housing and board. For use only with plans approved after 1/1/2008.

Form
F245-372-000


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

Form
F245-372-000


 
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


 
On-the-Job Training
Postcard: For employers; summarizes the benefits of providing on-the-job training to an injured worker. The other side is for injured workers who want to return to work; explains how on-the-job training can help them. Includes website address and contact information.

Publication
F200-021-000


 
Option 2: What You Need to Know, Vocational Rehabilitation Services
Booklet: Explains what happens when an individual selects "Option 2" and choose not to participate in the approved training plan.

Publication
F280-036-000


 
Plan Development Recommending Plan Approval 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 only if you are recommending Plan Approval. For all other closing reports, use Vocational Closing Report Routing Sheet (F252-027-000).

Form
F280-013-000


 
Plan Development Recommending Plan Approval 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 only if you are recommending Plan Approval. For all other closing reports, use Vocational Closing Report Routing Sheet (F252-027-000).

Form
F280-013-000


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

Form
F245-376-000


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

Form
F245-376-000


 
Self-Insurance Vocational Services Closing Cover Sheet
Used by self-insured employers, their representatives, and vocational counselors to summarize the outcome of a vocational rehabilitation plan when submitting the closing report.

Form
F207-171-000


 
Vocational Technical Stakeholder Group (VTSG) Application
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.

Form
F280-049-000


 





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