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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
 
Long Term Care Assessment Tool

You must mail or fax form. No emailed forms are accepted. This assessment tool is provided by L&I assessment to determine the medically appropriate level of care that will meet the Injured Worker’s needs, abilities and safety in a residential facility. This assessment is not intended as a substitute for DSHS annual assessment & treatment plan, which is the sole financial responsibility of the facility.



Form
F245-377-000
 
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
 
Temporary Services Guide to Workers' Compensation Insurance

Used by L&I to assign industrial insurance classifications for workers of temporary help agencies. The first file is a PDF of the Temporary Services Guide to Workers' Compensation Insurance. The second file is a 2003 Excel file. This file is a cross match of non temporary help classifications and the temporary help risk classification associated with that risk class. The third file is a 2003 Excel file. This is a reverse look up for temporary help risk classification and the non temporary classes associated with a temporary help class. File contains an instructions worksheet for the reverse look up worksheet.



Manual
F213-019-000
 
Independent Medical Examination Fax Cover Sheet
Independent Medical Examination Fax Cover Sheet

Form
F245-383-000
 
Notice of Independent Medical Exam No-Show or Late Cancellation
Notice of Independent Medical Exam No-Show or Late Cancellation

Form
F245-382-000
 
Employers' Guide to Self-Insurance in Washington State
Book: Explains the process for employers to provide their own industrial insurance (workers’ compensation) coverage in Washington State. Also reviews surety requirements for self-insurance, reporting and recordkeeping requirements, claims processing, and compliance and legal issues.

Publication
F207-079-000
 
Affidavit for Time Loss Compensation Benefits

Completed by injured workers contending eligibility for payment of back time loss benefits for a period that exceeds six months or $25,000. Injured workers requesting benefits for current time missed from work due to a work-related injury should use the F242-052-000 Worker Verification Form.



Form
F242-395-000

Alt Language(s):
Español
 
Electrical Safety Standards,Administration, and Installation WAC 296-46B

Electrical Safety Standards,Administration, and Installation WAC 296-46B



Manual
F500-039-222
 
Application to Reopen Claim due to Worsening Condition - Spanish Aplicación para Reabrir un Reclamo Debido al Empeoramiento de la Condición 

Spanish version. Used by injured workers and doctors to apply to reopen an industrial injury or occupational disease claim that has been closed for longer than 60 days.



Form
F242-079-999

Alt Language(s):
Inglés
English/Español
 
Hearing Aid Repair Authorization Fax Request

Hearing Aid Repair Authorization Requests. If you need to purchase or replace a hearing aid, fax all of the information required by Medical Aid Rules and Fee Schedule (MARFS) including the Hearing Services Worker Information (F245-049-000) to 360-902-6252.



Form
F245-384-000
 
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
 
Workers' Guide to Hazardous Chemicals: Understanding the Right-to-Know Law-English/Spanish (Gua del trabajador para el uso de qumicos peligrosos: Comprendiendo la Ley del derecho a saber)
Pamphlet/booklet: Explains Washington's chemical hazard communication standard, which requires employers to inform their employees about hazardous chemicals in the workplace and to train them in their proper use.

Publication
F413-014-909
 
Small Business Liaison Info Card
Introduces L&I's Small Business Liaison and the services provided, along with information on subscribing to the e-newsletter, L&I News for Small Business.

Publication
F101-088-000
 
How to Become a Certified Electrician: What You Need to Know about Certification in Washington State
Fact sheet: Provides information about getting a trainee card and outlines the electrical training and experience required to be certified as an electrician in Washington State.

Publication
F500-117-000
 
Green Power Generation System Installation: What You Should Know Before Doing Any Electrical Work
Fact sheet: Explains that an electrical permit and inspection are required for most new, remodel, and maintenance electrical work. Provides information specific to the installation of green power generation systems.

Publication
F500-116-000
 
Independent Medical Exam Doctor's Estimate of Physical Capacities

IME Doctor’s Estimate of Physical Capacities: For use by independent examiners when asked to estimate physical capacities as part of an IME requested by the department.



Form
F242-387-000
 
Affidavit_for_Time_Loss_Compensation_Benefits (Spanish) Declaración Firmada para Compensación de Tiempo Perdido

Affidavit_for_Time_Loss_Compensation_Benefits (Spanish) Declaración Firmada para Compensación de Tiempo Perdido Completed by injured workers contending eligibility for payment of back time loss benefits for a period that exceeds six months or $25,000. Injured workers requesting benefits for current time missed from work due to a work-related injury should use the F242-052-999 Worker Verification Form.



Form
F242-395-999

Alt Language(s):
Inglés
 
Protected Leave Complaint

For leave from work complaints: Download and complete a Protected Leave Complaint form (F700-144-000)



Form
F700-144-000

Alt Language(s):
Español
 
Farm Labor Contractor Certified Payroll
Farm Labor Contractor Certified Payroll

Form
F700-147-000
 
Casas prefabricadas y mviles: Lo que los dueos de casas y contratistas deben saber al modificar una vivienda

Pamphlet/booklet: Covers things you should consider when altering your home. Defines what is meant by alteration, repair and replacement and includes tips for hiring a registered contractor. It also includes contact information for L&I Consumer Assistance Program for owners of new manufactured/mobile homes.



Publication
F622-049-999

Alt Language(s):
Inglés
 
What You Should Know About Hiring a Contractor, Remodeler, or Handyman - Spanish (Lo que Usted Debe Saber paraContratar a un Contratista, Remodelador o Empleado de Mantenimiento (Handyman))  

Fact sheet: Provides a checklist for consumers considering hiring a general or specialty construction contractor, reviews the permitting process, and suggests ways to avoid lien problems. Washington State law requires construction contractors to register with L&I.



Publication
F625-084-999

Alt Language(s):
Inglés
 
Aplicando para su Licencia de Negocio en Washington: Una Guía Detallada

Pamphlet: Concise, easy-to-read pamphlet that explains the steps to apply for a business license and what to do if you plan to employ workers. Includes how to apply to be a registered construction contractor.



Publication
F101-079-999

Alt Language(s):
Inglés
 
Safety and Health Workshops

Pamphlet/Brochure: Introduces free workshops to help employers prevent workplace injuries and control workers' compensation costs. Includes course descriptions, and how to register.



Publication
F416-036-000
 
Help for Injured Workers of Self-Insured Businesses
Information card: Introduces the Office of the Ombudsman for Self-Insured Injured Workers. The ombudsman is appointed by the Governor to serve as an independent advocate for the rights of injured workers of self-insured employers.

Publication
F207-201-000

Alt Language(s):
Español
 
Your Independent Medical Exam: For Employees of Self-Insured Businesses
Pamphlet: Answers the most common questions about when and why an injured worker may be required to attend an independent medical exam. Includes the "IME Travel & Wage Reimbursement Request" form. This publication is for use only by self-insured businesses and their workers.

Publication
F207-202-000

Alt Language(s):
Español
 
Your Independent Medical Exam: For Employees of Self-Insured Businesses - Spanish (Su Examen Médico Independiente: Para empleadores de negocios autoasegurados)
Pamphlet: Answers the most common questions about when and why an injured worker may be required to attend an independent medical exam. Includes the "IME Travel & Wage Reimbursement Request" form. This publication is for use only by self-insured businesses and their workers.

Publication
F207-202-999

Alt Language(s):
Inglés
 
2008 Annual Report for the Washington State Fund: Washington's State-run Workers' Compensation Program

Book: Introduces Washington State's Workers' Compensation Program, including rate-setting and investment policies, financial statement overview, and services available to help employers control workers' comp costs.



Publication
F101-086-000
 
Job Analysis

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



Form
F252-072-000
 
Plain Talk Summary of Prevailing Wage Laws: Understand Your Responsibilities and Rights When Performing Public Work - Spanish (Resumen de las Leyes de Salario Prevaleciente en Lenguaje Sencillo Entienda sus Responsabilidades y Derechos al Hacer Trabajos Públicos)

8.5" X 11" sheets: Provides a summary of prevailing wage laws and rules in Spanish. This publication is only available in Spanish. For similar information in English, read the Washington State Prevailing Wage Law booklet.



Publication
F700-152-999
 
Standard Exception Classification

Quick reference card: Provides basic information about standard exception classifications, which can be separately rated from the basic business classification for determining industrial insurance (workers' compensation) premiums. This information is part of the publication, Workers’ Compensation Record Keeping and Report Guides.



Publication
F214-016-000
 
Notice of Completion of Public Works Contract

This is the form used by public agencies to request L&I's approval to release retainage. All contractors are to be listed on the request form with their associated affidavit id number.  Notices received without affidavit id numbers or incomplete information will not be processed and will be returned to the awarding agency. The first EXCEL document is in Office 2007 format. The second file, with the same title, is in Office 2003 format.



Form
F215-038-000
 
Letter of Intent for School Enrollment - Spanish Carta de Intención de Registro en una Escuela

Letter of Intent for School Enrollment - Spanish CARTA DE INTENCIÓN DE REGISTRO EN UNA ESCUELA



Form
F242-382-999

Alt Language(s):
Inglés
 
Worker Right Complaint Form (Spanish) Formulario de Queja sobre los Derechos Laborales

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



Form
F700-148-999

Alt Language(s):
Inglés
 
Instructions for completing the Workers' Compensation Employer's Quarterly Report

Instructions for completing the Workers' Compensation Employer's Quarterly Report. A sample of the form F212-055-000 is also available on the internet.



Form
F212-239-000
 
Board of Boiler Rules Washington State Specials Request Form
Board of Boiler Rules Washington State Specials Request Form

Form
F620-057-000
 
Board of Boiler Rules Extension of Inspection Frequency Request Form
Board of Boiler Rules Extension of Inspection Frequency Request Form

Form
F620-055-000
 
Chief Inspector Clarification and Interpretation Request Form
Chief Inspector Clarification and Interpretation Request Form

Form
F620-056-000
 
Affidavit of Continuity Medical Gas Installation

Affidavit of Continuity



Form
F627-043-000
 
Doctor's Worksheet for Rating Cervical and Cervico-Dorsal Impairment
Doctor's Worksheet for Rating Cervical and Cervico-Dorsal Impairment

Form
F252-056-000
 
Vocational Questionnaire/Work History

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



Form
F280-038-000

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

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



Form
F280-039-000
 
Renewal Application for Contractor Registration

Renewal Application for Contractor Registration



Form
F625-107-000
 
Contractor Registration Request for Duplicate License or Address Change  

This form may be faxed to the Contractor Registration office in Tumwater.



Form
F625-108-000
 
Structural Inspection Request Questionnaire

Structural Inspection Request Questionnaire



Form
F622-075-000
 
Roof Affidavit and Structural Inspection Request

The purpose of the manufactured home roof affidavit is to provide timely inspections and communications between the contractor and/or owner and FAS inspectors and field staff.

A structural inspection request questionnaire will not be required when a roof change out occurs if no structural changes are made in the roof sub-surface and roof cavity. Example: Repairing or replacing the roof trusses, rafters, ridge beam and the replacement of not more than (4) 4’x 8’ of roof sheathing.



Form
F622-076-000
 
2008 Annual Report - Department of Labor & Industries

Provides a statistical overview of operations in fiscal year 2008 (July 1, 2007, through June 30, 2008), budget information and a summary of accomplishments during the fiscal year.



Publication
F101-089-000
 
Robberies and Abusive Customers: Tips for Preventing Injuries-Spanish (Robos y Clientes Abusivos: Consejos para Prevenir Lesiones)

Tips on handling cash and how to have a safer restaurant or retail environment. Get poster printing tips.



Poster
FSP0-919-999

Alt Language(s):
Inglés
 
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
 
Help for Injured Workers of Self-Insured Businesses-Spanish (Ayuda para Trabajadores Lesionados de Empresas Autoaseguradas)

Information card: Introduces the Office of the Ombudsman for Self-Insured Injured Workers. The ombudsman is appointed by the Governor to serve as an independent advocate for the rights of injured workers of self-insured employers.



Publication
F207-201-999

Alt Language(s):
Inglés
 
Need a Doctor?
Information card: Provides contact information for injured workers needing assistance in finding a health-care provider who will treat their occupational injury or disease. This PDF will print out an 8.5" X 11" sheet that has 12 copies of the card. Note: Disclaimer information on Page 2 may not line up accurately in two-sided printing.

Publication
F160-006-000

Alt Language(s):
Español
 
Need a Doctor? - Spanish (¿Necesita un doctor?)
Information card: Provides contact information for injured workers needing assistance in finding a health-care provider who will treat their occupational injury or disease. This PDF will print out an 8.5" X 11" sheet that has 12 copies of the card. Note: Disclaimer information on Page 2 may not line up accurately in two-sided printing.

Publication
F160-006-999

Alt Language(s):
Inglés
 
Hiring Teens this Summer? - Spanish (¿Piensa contratar adolescentes este verano?)
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
F700-142-999

Alt Language(s):
Inglés
 
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
 
Protected Leave Complaint Form - Spanish - Queja sobre el Permiso de Ausencia Protegida

Para quejas de ausencia del trabajo: Descargue y complete un formulario de Queja sobre permiso de ausencia protegida (F700-144-999)



Form
F700-144-999

Alt Language(s):
Inglés
 
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
 
Occupational Disease Employment History of Hearing Loss and Continuation Sheet - Spanish - Historia de Trabajo - Pédida de Audición

History of Hearing Loss and Continuation Sheet - Spanish - HISTORIA DE TRABAJO PÉRDIDA DE AUDICIÓN



Form
F262-013-999

Alt Language(s):
Inglés
Inglés
 
Affidavit of Wages Paid Addendum A Additional List of Crafts

Please use this addendum to list additional Crafts/Trades/Occupations when filing an Affidavit of Wages of Paid and you need to list more Crafts/Trades/Occupations than the Affidavit of Wages Paid form can accommodate. This is the addendum A to form F700-007-000.



Form
F700-161-000
 
Affidavit of Wages Paid Addendum C Additional Information

Please use this addendum to provide any additional information you want to communicate to L&I when you file an Affidavit of Wages of Paid. Addendum C is for form F700-007-000.



Form
F700-162-000
 
Statement of Intent to Pay Prevailing Wages Addendum A

Please use this addendum to list additional Crafts/Trades/Occupations when you need to add more Crafts/Trades/Occupations than the Statement of Intent to Pay Prevailing Wages form can accommodate. Addendum A is for form F700-029-000.



Form
F700-160-000
 
Statement of Intent to Pay Prevailing Wages Addendum C

Please use this addendum to provide any additional information you want to communicate to L&I when you file a Statement of Intent to Pay Prevailing Wages. Addendum C is for form F700-029-000.



Form
F700-163-000
 
Farm Internship Agreement

Agreement form: Prior to hiring an intern, farms that have received a Farm Intern Program certificate must complete this agreement with the intern and submit it to the department.



Form
F700-157-000
 
Application for Farm Internship

Application form: Small farm owners wishing to participate in the pilot small farm internship program must complete this form and submit it to the department. The information requested on the form is required to process an application for approval in order to issue a certificate of participation.



Form
F700-158-000
 
An Annual Electrical Permits Saves Time and Money. Would it Work for You?

Flier: Describes when facility operators/owners qualify for an annual electrical permit.



Publication
F500-123-000
 
START Program (Safety through Achieving Recognition Together)
Fact sheet: Provides an overview of START, a program that recognizes occupational safety and health excellence in small businesses. Includes program requirements and benefits.

Publication
F417-229-000
 
Pension and Survivor Benefits in Washington State's Workers' Compensation Program--English/Spanish (Beneficios de Pensión y para Sobrevivientes del Programa de Compensacin para Trabajadores de Washington)

Pamphlet/booket: Answers the most common questions about pension and survivor benefits under Washington's workers' compensation program.



Publication
F242-352-909
 
L&I Chiropractic Consultant Application
This application is for doctors applying for second opinion examiner (consultant) status. Current consultants do not need to reapply.

Form
F245-393-000
 
CVCP Opioid Progress Report Chronic, Non-Cancer Pain and Treatment Agreement.
Crime Victims Compensation Opioid Progress Report Chronic, Non-Cancer Pain and Treatment Agreement.

Form
F800-116-000
 
Electrical Telecommunication Principal Member Owner Update Request

Electrical Telecommunication Principal Member Owner Update Request



Form
F500-124-000
 
F245-392-000 Resource Utilization Group (RUG) Residential Care Services for L&I Injured Workers (In place of MDS 3.0 beginning October 1, 2010.)
Filled out by the provider when they treat an injured worker. See web links below for: Latest payment amounts, Updates and corrections, and Review payment policy. For use in place of Minimum Data Set (MDS) 3.0 beginning October 1, 2010.

Form
F245-392-000
 
Affidavit of Wages Paid EHB 2805 Addendum
F700-164-000 is an addendum to your Affidavit of Wages Paid Form. RCW 39.04.370 requires you to complete form F700-164-000 if the prime contract is at a cost of over one million dollars ($1,000,000). If you fail to properly provide the requested information more than one time between September 1, 2010 and December 31, 2013, pursuant to RCW 39.04.350(1)(f) you will not be considered a responsible bidder qualified to be awarded a public works project. Use as many of these forms as you need in order to provide the requested information for all relevant project items. This is an addendum to form F700-007-000.

Form
F700-164-000
 
Challenging Times Demand Our Best
Booklet: Describes how L&I is making changes, both big and small, to better serve our customers and operate efficiently. Three areas of focus are fighting fraud, putting customers first and cutting costs. Features stories about three customers L&I has helped.

Publication
F101-095-000
 
Self-Insurer Accident Report (SIF-2)

Provided to workers by the self-insured businesses or their third party claims administrators to report an industrial injury or occupational disease. This form is not on the internet. If you are an injured worker, ask your employer for a copy of this form. Self-insured businesses or their third party claims administrators may order copies of this form. Cllick the "order It" button below to order paper copies or request the form in MSWord.



Form
F207-002-000
 
Provider's Initial Report (PIR)

Used by medical providers when reporting initial treatment for an industrial injury or occupational disease for a self-insured claim. The paper version dated 10-2012 is still valid, as is the 01-2014 word fillable version.

Medical providers treating self-insured workers, self-insured businesses, or their third party claims administrators can access this form one of two ways:

  1. Download the Microsoft (MS) Word form and the PDF file with instructions:

           The first file is the PDF instructions.

           The second file is an Office 2003 MSWord document ending in .doc.

           The third file is an Office 2007/2010 version, ending in .docx.

2.  Order paper copies of this form by clicking the “order it” button.



Form
F207-028-000
 
Stop Work Payroll Report
Stop Work Payroll Report

Form
F262-043-000
 
HCFA Proprietary Format Companion Guide
This guide details the HCFA proprietary format structure and provides information regarding electronic billing to the department via Provider Express Billing (PEB).

Form
F245-394-000
 
Sports Player Coverage Agreement

Used by a sports team or league and professional athlete (player) to declare that the player's work is principally localized in another state in accordance to the provisions of RCW 51.12.120 and WAC 296-17-32503.



Form
F212-242-000
 
Safety for Commercial Dive Teams
Fact sheet: Provides an overview of safety for commercial dive teams, summarizes the key requirements of commercial diving regulations (WAC 296-37), and includes contact information.

Publication
F417-226-000
 
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
 
Avoid Liability for Your Farm Labor Contractor's Unpaid Debits (English/Spanish) / Evite su Obligación por las Deudas no Pagadas de su Contratista de Trabajadores Agrícolas

Fact sheet: Explains how employers could be liable for unpaid workers' compensation premiums, unpaid wages, damages and civil penalties when hiring a farm labor contractor. Outlines ways to protect against potential liability.



Publication
F700-154-909
 
Fall Protection Work Plan Requirements

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



Form
F417-107-000
 
Manufactured Home Installer Certification Tag Order form

Manufactured Home Installer Certification Tag Order form



Form
F622-077-000
 
Manufactured Home Installer's Monthly Certification Tag Report

Manufactured Home Installer's Monthly Certification Tag Report



Form
F622-078-000
 
Manufactured Home Installer Certification Tag Transfer Request form

Manufactured Home Installer Certification Tag Transfer Request form



Form
F622-079-000
 
Plan Time Encumbrance
To record the work plan time. For use only with plans approved after 1/1/2008.

Form
F245-376-000
 
Affidavit of Wages Paid Addendum D

Please use this addendum to provide the details of the Apprentices associated with your Affidavit of Wages of Paid. Addendum D is for form F700-007-000.



Form
F700-165-000
 
A Safe and Healthy Workplace Begins with You
Pamphlet: Provides an overview of employers' responsibilities for workplace safety and health in Washington State. Covers free L&I services, including workplace consultations, online training and prevention resources and required posters. Intended for new businesses or businesses hiring employees for the first time.

Publication
F417-210-000
 





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