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Physical Therapy / Occupational Therapy Progress Report to Claim Managers

The physical / occupational therapist uses this report to identify the clinical goals and return to work objectives of the injured worker.



Form
F245-059-000
 
Registered Apprenticeship Program Address/Mailing Information Update

Used by the Registered Apprenticeship Program to update their address or mailing information. (Note: This DOES NOT update your program standards information.) You should ensure that your address information in the Standards is correct.



Form
F100-512-000
 
Equal Employment Opportunity (EEO) Resource & Referral Update Form

Used by an organization to get on the Apprenticeship Program equal opportunity resources list or use to update their information on the list.



Form
F100-513-000
 
Log of Good Faith Effort Documentation

This is for Registered Apprenticeship Programs to record Good Faith Effort activities in accordance with their Registered Apprenticeship Standards (Equal Employment Opportunity Plan)



Form
F100-515-000
 
Apprenticeship Related Supplemental Instruction (RSI) Plan Review Glossary of Terms
Glossary of terms used with Apprenticeship Related Supplemental Instruction (RSI) Plan Review form and RSI Plan.

Form
F100-519-000
 
Apprenticeship Related Supplemental Instruction (RSI) Plan Review

Used by apprenticeship programs/sponsors as part of the process of getting new programs/standards/occupations approved.



Form
F100-520-000
 
Apprenticeship Related Supplemental Instruction (RSI) Plan Revew Review Criteria
Describes the process for getting approval of new or revised RSI for new apprenticeship programs/standards/occupations.

Form
F100-521-000
 
Training Agent Agreement and Understanding of Equal Employment Opportunity (EEO) Requirements of the Apprenticeship Committee - Alternate Selection Process

This should be signed by all employers who are Training Agents with Apprenticeship Programs that use an Alternate Selection Process. This also explains their obligations and rights as part of this process.



Form
F100-523-000
 
Washington State Apprenticeship Programs Catalog
Book: Provides an overview of apprenticeship, explains general requirements, lists the apprenticeship programs in Washington State and, and provides contact information. The version available online may contain more up-to-date information than the June 2012 printed edition.

Publication
F100-041-000
 
Summary of Agricultural Employment Regulations and Farm Contractor Requirements

This summary is on employment laws relating to the agricultural industry.



Publication
F700-124-000
 
Agricultural Employer Worksheet

Used by agricultural employers to assist them in determining if they are following the state Agricultural Employment Standards and the Minimum Wage Act for their employees.



Form
F700-125-000
 
Avoid Liability for Your Subcontractor's Unpaid Workers' Comp Premiums
Fact sheet: Tells construction contractors how to protect themselves from liability for their subcontractor's unpaid workers' compensation premiums.

Publication
F262-262-000

Alt Language(s):
Español
 
Preparing for Your Self-Insurance Audit

Pamphlet/booklet: Helps self-insured employers understand and prepare for an audit.



Publication
F207-110-000
 
The ABCs of Classifications in Washington
Book: Aids in understanding Washington State's workers' compensation classification system and how classifications are applied to different types of businesses.

Publication
F213-022-000
 
Frequently Asked Questions about Job Modifications
Fact sheet: Answers questions employers, workers and doctors may have about job modifications, including when to request a job-modification consultant and who pays for the costs involved.

Publication
F245-057-000
 
¿Lesionado por un tercero? Usted tiene opciones legales - English (Injured by a Third Party? You Have Legal Options)
Folleto: Un resumen de los derechos legales y opciones que tiene un trabajador lesionado si una acción contra un tercero está relacionada con su reclamo de compensación para los trabajadores. Incluye el Formulario de elección contra terceros que debe ser completado por el trabajador. Aviso. El formulario debe imprimirse, firmarse y enviarse por correo.

Form
F249-008-999

Alt Language(s):
Inglés
 
Workers' Compensation Discrimination-English/Spanish (Discriminación porque se lesionó en su trabajo)
Fact sheet: Explains workers' legal right to file a workplace injury claim and how to file a complaint if discrimination has occurred.

Publication
F262-249-909
 
Your Lungs, Your Work, Your Life: What You Should Know about Work-related Asthma

Pamphlet/booklet: Briefly reviews the symptoms and causes of work-related asthma and explains prevention and treatment approaches.



Publication
F413-060-000

Alt Language(s):
русский
Español
 
Sus Pulmones Su trabajo Su vida: Lo que debería saber acerca del asma ocupacional
Pamphlet/booklet: Briefly reviews the symptoms and causes of work-related asthma and explains prevention and treatment approaches.

Publication
F413-060-999

Alt Language(s):
Inglés
русский
 
Forklift Safety Guide
Book: Provides general information on kinds of forklifts, principles of physics that apply to forklifts, training requirements for forklift operators, basic operator safety rules, dangers of carbon monoxide, and safety while servicing a forklift.

Publication
F417-031-000
 
Agricultural workers information line (English/Spanish)
Card: Wallet card with a toll-free telephone number where agricultural workers can call to learn about their workplace rights.

Publication
F700-103-909
 
Job Site Safety: Wear Your Hard Hat
Poster: Visual reminder you can print for posting at appropriate job sites and use in safety training, crew or safety committee meetings.

Poster
FSP0-907-000
 
Stay Clear of Suspended Loads
Pictures a guy under a suspended wooden carton. Get poster printing tips.

Poster
FSP0-908-000
 
The Best Accident Insurance - To observe all safety regulations
Picture of a guy with Saftey Policy and Rules in his hand. Get poster printing tips.

Poster
FSP0-915-000
 
Four Steps to Proper Lifting
Pictures of a person lifting a large box correctly along with tips on how to correctly lift a large item safely. Get poster printing tips.

Poster
FSP0-918-000
 
Robberies and Abusive Customers: Tips for Preventing Injuries
Tips on handling cash and how to have a safer restaurant or retail environment. Get poster printing tips.

Poster
FSP0-919-000
 
Always Wear Eye Protection
Picture of a large eye with some content on when to use eye protection. Get poster printing tips.

Poster
FSP0-940-000

Alt Language(s):
Español
 
Safe Ways - Fork Lift Safety
Safety tips on using a fork lift. Get poster printing tips.

Poster
FSP0-978-000
 
Well...My Daddy Wears 'Em
Little boy wearing his daddy's hard hat, eye protection, gloves and boots. Get poster printing tips.

Poster
FSP1-010-000
 
Watch Where You Step
Large lettering: Watch Where You Step. Get poster printing tips.

Poster
FSP1-055-000
 
High Noise Area, Wear Hearing Protection
Cartoon of a guy plugging his ears with his fingers while his hearing protection is wrapped around his neck with the words 'High Noise Area' above his head. Get poster printing tips.

Poster
FSP1-065-000
 
Si usted TIENE que remover este resguardo 5 1/2 x 2 1/8

Sticker: 5.5 inches X 2.15 inches



Sticker
FSP0-993-991

Alt Language(s):
Inglés
 
Independent Contractor Guide: A Step-by-Step Guide to Hiring Independent Contractors in Washington State

Pamphlet/booklet: A step-by-step guide to hiring independent contractors in Washington State. This publication is a general guide to help you understand how and when the Department of Labor & Industries applies workers’ compensation laws to independent contractors.



Publication
F101-063-000

Alt Language(s):
Español
 
Guía para Contratar Contratistas Independientes en el Estado de Washington

Pamphlet/booklet: Designed to help employers determine if their workers are employees or independents under Washington's workers' compensation, workplace safety, wage and hour and unemployment tax laws. Includes a short "test" and helpful references.



Publication
F101-063-999

Alt Language(s):
Inglés
 
Self-Insurance Certification Questionnaire

Used by employers applying to become self-insured to describe their proposed workers' compensation program.



Form
F207-176-000
 
General Provider Billing Manual

General billing information for those providers that bill the department.



Manual
F248-100-000
 
Your Lungs, Your Work, Your Life: What You Should Know about Work-related Asthma (Russian)
Pamphlet/booklet: Briefly reviews the symptoms and causes of work-related asthma and explains prevention and treatment approaches.

Publication
F413-060-444

Alt Language(s):
Inglés
Español
 
Pocket Guide to Caution Zone Jobs

Pamphlet/booklet: This advisory pocket guide reviews 14 workplace risk factors that can lead to soft tissue injuries such as back strain, tendinitis and carpal tunnel syndrome. Suggests ways to identify the risk factors. Lists helpful resources from L&I.



Publication
F417-195-000
 
Construction Contractor's Application for Workers' Compensation Account with No Workers or Hours

Used by employers with no employees or worker hours to report but need an open account for contract bidding process.



Form
F625-077-000
 
Reporte Trimestral para la Industria de Tabla de Yeso

Used by drywall employers as a guide to completing quarterly and supplemental reports. This includes filled out samples of F212-050-000 and F212-051-000.



Form
F212-224-999

Alt Language(s):
Inglés
 
Cholinesterase Monitoring Reimbursement Request

Employers use this form to request reimbursement for the reasonable costs of training, travel, recordkeeping, and medical expenses for Cholinesterase Monitoring.



Form
F413-062-000
 
Agency Requested Inspection
Used by non-L&I agencies and jurisdictional authorities to request an inspection on an electrical hazard.

Form
F500-025-000
 
Chapter 19.28 RCW - Electricians and Electrical Installations
Simplified version of the Chapter 19.28 RCW - Electricians and Electrical Installations Rules

Manual
F500-039-111
 
Application for Accreditation of Engineer to Approve Industrial Utilization Equipment

Used by an Engineer to apply for accreditation by L&I to approve unlisted equipment.



Form
F500-101-000
 
Application for Pump Installer Combination General Contractor Registration and Electrical Contractor License

Used for creating combination electrical and plumbing contractors license



Form
F500-104-000
 
Plumber Request for Change of Address
Plumber Request for Change of Address

Form
F627-039-000
 
Renewal of Contractor Elevator License

Used by Elevator Companies to renew their Contractor License.



Form
F621-082-000
 
SIF-4 Self Insured Employer's Request for Denial of Claim
Used by self-insured employers or their representatives to notify an injured worker that the employer or representative is requesting that L&I deny their claim.

Form
F207-163-000
 
How to Ride Safely on Elevators, Escalators and Moving Walks
Pamphlet/booklet: Provides safety tips and interesting facts to promote safe use of elevators, escalators and moving walks.

Publication
F621-084-000
 
Electrical Work on Residential Property: What You Should Know Before Work Begins
Fact Sheet: Explains to property owners the importance of electrical permits, inspections and approvals. An electrical permit is required for most new, remodel and maintenance electrical work.

Publication
F500-078-000
 
Vendor / Medical Conversion Units Pre-Inspection Checklist

Pre-Inspection Checklist to assist vendor owners, manufacturers, and others on what they need to know to get their vendor/medical unit approved by Labor and Industries.



Form
F622-072-000
 
New/Update Elevator Company Primary Point of Contact

Used by the Elevator Section only to Change and/or Update the Primary Point of Contact for Elevator Companies



Form
F621-086-000
 
Performance Based Physical Capacities Evaluation

Used by occupational and physical therapy providers as an optional reporting format for a Performance-based Physical Capacities Evaluation.



Form
F245-023-000
 
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 or needs further vocational services such as retraining.



Form
F252-029-000
 
Board of Boiler Rules Interpretation and Revision Request Form
Used to submit written requests for interpretations and revisions to the definitions, rules and regulations found in WAC 296-104. These must be submitted 45 days prior to the Board of Boiler Rules Meeting date. To use this form, left click on the link and select SAVE TARGET AS and save to your desktop. Open in WORD, complete form, select PRINT, SEND TO, MAIL or DELIVERY DOCUMENT ONLY in care of Chief, Boiler Inspector.

Form
F620-017-000
 
What Are Your Rights as a Worker?

Fact sheet: Provides a brief overview of the worker rights administered by the Department of Labor and Industries. These include certain employment-related rights and rights pertaining to workplace safety and workers' compensation benefits.



Publication
F101-061-909

Alt Language(s):
English/កម្ពុជា
English/한국의
English/русский
English/Việt
 
Pre-Inspection Checklist for High Pressure Boilers

Checklist which reflects the most common violations found by Field Inspectors. This checklist should be gone through prior to calling for an inspection of High Pressure Boilers



Form
F620-053-000
 
Parent / School Authorization for Employment of a Minor and Special Variance

For legal guardians and school officials to approve the hours and work activities for a minor employee to work according to terms listed by the employer. The Special Variance allows additional hours of work for 16- and 17-year-olds and is described on the form. All parties must sign to approve the hours of work for a minor regardless of the number of hours listed. This is NOT a work permit. Employers must obtain a minor work permit endorsement on their Master Business License where they employ workers under 18.

For hiring youth only during non-school weeks, you may use form F700-168-000 Parent Authorization Summer Work  



Form
F700-002-000
 
Record Keeping Provisions - Employment Standards

This form is for employers to use to keep records on every employee.



Form
F700-009-000
 
Pre-Inspection Checklist for Low Pressure Steam Boilers

Checklist which reflects the most common violations found by Field Inspectors. This checklist should be gone through prior to calling for an inspection of Low Pressure Steam Boilers



Form
F620-052-000
 
Application for Farm Labor Contractor License

Used to apply or renew a license.



Form
F700-014-000
 
Teens at Work: Facts for Employers, Parents and Teens

Pamphlet/booklet: Answers questions employers, parents and teens may have about employing teen workers (ages 14-17). Explains non-agriculture work rules, including the necessary permits, hours and work conditions. Provides links to other resources.



Publication
F700-022-000

Alt Language(s):
Español
 
Pre-Inspection Checklist for Potable Water Heaters - ASME "HLW" Stamped Water Heaters
Checklist which reflects the most common violations found by Field Inspectors. This checklist should be gone through prior to calling for an inspection of Potable Water Heaters-HLW

Form
F620-051-000
 
Wage Transcription and Computation Sheet

Employer uses this to show time worked and wages earned for an employee.



Form
F700-024-000
 
Prevailing Wage Complaint and Instructions

Ask L&I to conduct an investigation into a prevailing wage violation that affects one or more employees. See box 30 on the form to see what types of complaints are covered.



Form
F700-146-000

Alt Language(s):
Español
 
Pre-Inspection Checklist for Hot Water Heating or Hot Water Supply Boilers
Checklist which reflects the most common violations encountered by Field Inspectors. This checklist should be gone through prior to requesting inspection of Hot Water Heating or Hot Water Supply Boilers

Form
F620-050-000
 
Farm Labor Contractor Assignment of Account or Time Deposit

Farm Labor Contractor assignment of account or tme deposit for employee



Form
F700-060-000
 
RCW 43.22.380 Exemptions Fire and Safety Checklist for Vendor/Medical Conversion Units
Generic Checklist to determine if the particular installation includes all requirements prior to calling for an inspection. Must be able to answer YES to all questions prior to calling.

Form
F622-073-000
 
Payment of Wages - RCW 49.48.010 and 49.52.050

This is a copy of the law that pretains to the payment of wages to an employee when they stop working for an employer. The wages due to the employee for the pay period worked prior to leaving.



Form
F700-064-000
 
Farm Labor Contractors Bond

Notarized farm labor contractors bond coverage.



Form
F700-066-000
 
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
 
Variance Application - For exceptions from specific rules governing employment of minors.

Employer uses this application for requesting a variance to employment regulations for minors.



Form
F700-076-000
 
Washington State OverTime Law

Covers compensation for employees in Washington State working overime.



Publication
F700-079-000
 
Farm Labor Contractor Registration

Fact Sheet: Explains how to get a farm labor contractor license in order to operate legally as a farm labor contractor in Washington State.



Publication
F700-088-000

Alt Language(s):
Español
 
Variance Application - Employment Standards

Employer application request for a variance from employment standards for non minor employees.



Form
F700-089-000
 
Washington State Deduction Laws

Deductions for current & terminated employees and employer liability for paying less than required.



Form
F700-097-000
 
Internal Revenue Service Tax Compliance Certification

Form to gain Internal Revenue Service Tax Compliance Certification for registered Farm Labor Contractors. Now includes IRS form 8821 Tax Information Authorization.



Form
F700-098-000
 
Interested Party Checklist for the Filing of Prevailing Wage Complaints

Checklist used for the filing of Prevailing Wage Complaints by "Interested parties" ONLY.



Form
F700-129-000
 
Department of Employment Security Tax Compliance Certification

Form to gain Department of Employment Security Tax Compliance Certification for registered Farm Labor Contractors.



Form
F700-099-000
 
Department of Revenue Tax Compliance Certification

Form to gain Department of Revenue Tax Compliance Certification for registered Farm Labor Contractors.



Form
F700-100-000
 
Panel Load Calculations

Listing of Connected Loads and the Demand Loads. Used for all appliances that are fastened in place, permanently connected on specific circuit. Single Phase Panel Schedule and Three Phase Panel Scheule inlcude. Sample diagram included.



Form
F623-017-000
 
Farm Labor Contractor Complaint Form

Used to file a complaint against a Farm Labor Contractor, landowner, employer, or other where a possible infraction is concerned.



Form
F700-109-000

Alt Language(s):
Español
 
Farm Labor Contractor Checklist

Farm Labor Contractor's Checklist to ensure compliance.



Form
F700-112-000

Alt Language(s):
Español
 
Employing Children Under Age 14 in Non-Agricultural Jobs

Fact sheet: Explains when employers can and cannot employ minors under age 14 in non-agricultural jobs. Details the process for obtaining court permission when hiring minors under 14 is allowed.



Publication
F700-117-000
 
2005 Annual Report - Department of Labor & Industries

Provides a statistical overview of results achieved in fiscal year 2005 (July 1, 2004, through June 30, 2005), budget information and a narrative introduction to the Department of Labor and Industries.



Publication
F101-068-000
 
Employer Petition to The Court for Minor Work Permit Under Age 14

Petition to The Court for Minor Work Permit Under Age 14 by Employer.



Form
F700-118-000
 
Court Form Granting Permission for Employment of Minors

Form from Court Granting Permission for Employment of Minors to the employer.



Form
F700-119-000
 
Declaración para Servicios Misceláneos

Este formulario es utilizado por proveedores y trabajadores lesionados para cobrarle al Departamento por servicios tales como, cuidado dental; lentes; cuidado de enfermería en el hogar; equipo médico, servicios de intérprete; servicios que los trabajadores pagan por su cuenta y otros servicios.



Form
F245-072-999

Alt Language(s):
Inglés
 
Application for Special Certificate to Employ at A Subminimum Wage Rate

Employer Application for Special Certificate to Employ at A Subminimum Wage Rate.



Form
F700-120-000
 
Application for Special Certificate to Employ A Vocationally Handicapped Worker at at Subprevailing Wage Rate

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



Form
F700-122-000
 
Minimum Wage Law Exemptions

Covers exemptions to Washington state minimum wage law.



Publication
F700-051-000
 
Employer Rights - Wages Paid

Covers penalties for employer wage violations. Once stock runs out in warehouse, this form will be internet only.



Form
F700-058-000
 
Washington State Prevailing Wage Law

Booklet: Contains the prevailing wage laws (RCWs) and rules (WACs) as well as plain language descriptions and contact information.



Publication
F700-032-000
 
2006 Annual Report - Department of Labor & Industries
Provides a statistical overview of results achieved in fiscal year 2006 (July 1, 2005, through June 30, 2006), budget information and a narrative introduction to the Department of Labor & Industries.

Publication
F101-078-000
 
Sports Teams and Youth Workers

Fact sheet: Explains the requirements for sports organizations that engage young people as volunteers or employees to referee, assist or work for the organizations. The focus is workers' compensation coverage and minor work rules.



Publication
F700-130-000
 
Protegiendo a los trabajadores de Washington (Protecting Washington Workers)
DVD: An innovative tool to teach Spanish-speaking workers about workplace rights while introducing English terminology.

DVD
F130-004-909
 
Application for House to House Sales Sales Employer Registration Certificiate

Used by employers to register as employing minors who will be engaged in house-to-house sales, as required by WAC 296-125-024, with Labor and Industries.



Form
F700-121-000
 
Hiring Teens this Summer?

Flier: Provides important information about hiring teens, including extra safety precautions, as well as legal requirements regarding minor work endorsement, hours and prohibited duties. Provides telephone, e-mail and Web contacts for more information.



Publication
F700-142-000
 
What Are Your Rights as a Worker? (English/Russian)
Fact sheet: Provides a brief overview of the worker rights administered by the Department of Labor and Industries. These include certain employment-related rights and rights pertaining to workplace safety and workers' compensation benefits.

Publication
F101-061-404

Alt Language(s):
English/កម្ពុជា
English/한국의
English/Español
English/Việt
 
Worker Rights Complaint Form

This is the Worker Rights Complaint Form. Both the 12-2011 and 10-2010 versions are valid.



Form
F700-148-000

Alt Language(s):
Español
 
What Are Your Rights as a Worker? (English/Vietnamese)
Fact sheet: Provides a brief overview of the worker rights administered by the Department of Labor and Industries. These include certain employment-related rights and rights pertaining to workplace safety and workers' compensation benefits.

Publication
F101-061-505

Alt Language(s):
English/កម្ពុជា
English/한국의
English/русский
English/Español
 
Wage-and-Hour Questions Employers Often Ask

Fact sheet: Provides answers to questions related to pay requirements, deductions from pay, hiring a teen worker, employee uniforms and access to personnel file. Includes contact information if an employer needs assistance with a specific situation.



Publication
F700-150-000
 
What Are Your Rights as a Worker? (English/Cambodian)
Fact sheet: Provides a brief overview of the worker rights administered by the Department of Labor and Industries. These include certain employment-related rights and rights pertaining to workplace safety and workers' compensation benefits.

Publication
F101-061-606

Alt Language(s):
English/한국의
English/русский
English/Español
English/Việt
 
What Are Your Rights when You Work for a Farm Labor Contractor? (English/Spanish) / ¿Cúales son sus derechos cuando trabaja para un contratista de trabajadores agrícolas?

Fact sheet: Provides an overview of rights workers have when they are employed by a farm labor contractor. Several topics are covered, including regular wages, workplace safety, and help if injured on the job.



Publication
F700-067-000
 





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