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    Preferred Worker Request: Job Analysis Employer's Job Description

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    ElementsRook
    This document is a request form for preferred worker status in Washington state. It has two parts: 1. The first part requests that an injured worker be granted preferred worker status. It requires documentation showing the worker can no longer perform their previous job due to injury-related medical restrictions and has reached maximum medical improvement. 2. The second part is for a hiring employer to request approval of a job for the preferred worker. It requires documentation of a job offer within the worker's restrictions approved by their healthcare provider. The form collects identifying and contact information for the injured worker, requester, and potential employer to process the preferred worker request.

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    Preferred Worker Request: Job Analysis Employer's Job Description

    Uploaded by

    ElementsRook
    51 views2 pages
    This document is a request form for preferred worker status in Washington state. It has two parts: 1. The first part requests that an injured worker be granted preferred worker status. It requires documentation showing the worker can no longer perform their previous job due to injury-related medical restrictions and has reached maximum medical improvement. 2. The second part is for a hiring employer to request approval of a job for the preferred worker. It requires documentation of a job offer within the worker's restrictions approved by their healthcare provider. The form collects identifying and contact information for the injured worker, requester, and potential employer to process the preferred worker request.

    Original Description:

    prefered worker program

    Original Title

    F280-060-000(2)

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    This document is a request form for preferred worker status in Washington state. It has two parts: 1. The first part requests that an injured worker be granted preferred worker status. It requires documentation showing the worker can no longer perform their previous job due to injury-related medical restrictions and has reached maximum medical improvement. 2. The second part is for a hiring employer to request approval of a job for the preferred worker. It requires documentation of a job offer within the worker's restrictions approved by their healthcare provider. The form collects identifying and contact information for the injured worker, requester, and potential employer to process the preferred worker request.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    51 views2 pages

    Preferred Worker Request: Job Analysis Employer's Job Description

    Uploaded by

    ElementsRook
    This document is a request form for preferred worker status in Washington state. It has two parts: 1. The first part requests that an injured worker be granted preferred worker status. It requires documentation showing the worker can no longer perform their previous job due to injury-related medical restrictions and has reached maximum medical improvement. 2. The second part is for a hiring employer to request approval of a job for the preferred worker. It requires documentation of a job offer within the worker's restrictions approved by their healthcare provider. The form collects identifying and contact information for the injured worker, requester, and potential employer to process the preferred worker request.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 2

    Preferred Worker Request

    Mail or fax completed forms to:


    PO Box 44291 Worker’s Name Claim Number
    Olympia WA 98504-4291
    Or fax to: 360-902-4567 Job of Injury Title

    A. Request preferred worker status for injured worker


    (Vocational providers often complete this section. Not a voc provider and need help? Call your VRC or 800-845-2634).

    Requirements injured worker must meet for preferred worker* status. (State Fund workers only)

    1. The worker’s health care provider has permanently restricted the worker from returning to the work
    they were doing at the time of the injury.
    Attach one of the following required documents:
    A completed and signed Job Analysis or Employer’s Job Description for the job of injury showing the
    worker’s health care provider’s permanent disapproval.
    Medical information in the claim file clearly indicating that the worker is permanently restricted from
    performing the job of injury and specifying which duties the worker is unable to do.
    2. The work restrictions given by the health care provider are supported by medical findings related
    to the accepted condition.
    Attach this required document:
    Chart note or Independent Medical Exam (IME) containing medical findings related to accepted
    medical condition in claim (Large volumes of information are unnecessary.)
    3. Further recovery is not expected, due to the worker’s permanent loss of physical or mental
    function related to the accepted condition.
    Attach this required document:
    Chart note, Activity Prescription Form (APF), or IME indicating the worker has either:
     Completed treatment
    OR
     Is at or near maximum medical improvement.

    Submitted by

    Print name of person submitted packet If not worker, print job title and business or firm name

    VRC provider number (if applicable) Phone number

    VRC ID number (if applicable) VRC firm provider number (if applicable)

    Submitter’s Signature (required) Date (required)

    F280-060-000 Preferred Worker Request 08-2016 Index: 2PWP


    Preferred Worker Request
    Worker’s Name Claim Number

    B. Request approval of preferred worker job


    (Hiring employer completes this section. Need help? Call your VRC or the phone number below.)
    Hiring employer’s business name L&I account number

    Employer’s mailing address

    City State Zip Code

    Phone number Fax number

    Worker’s new job title Date of hire / Start date

     Does this worker currently have preferred worker status?


    Yes No (If ‘No’, apply on Part A of this form)
     Did the worker’s health care provider approve the job and find it within the worker’s documented
    medical restrictions?
    Yes No
     Are you (the employer) in good standing with L&I?
    Yes No (To check, go to: www.Lni.wa.gov/Verify)
     Are you (the employer) ‘self-insured’ for workers’ compensation coverage in Washington?
    Yes No Not sure what self-insurance is? Go to www.Lni.wa.gov/SelfInsurance
    If you answered ‘yes’ to the above question, was the worker certified as a preferred worker under a
    State Fund claim on or after January 1, 2016?
    Yes No

    Required Attachments
    Job Analysis or Employer’s Job Description ― approved by the health care provider and consistent with
    work restrictions in the worker’s L&I claim file.
    Formal job offer signed by the worker and employer.

    Sign below to certify that the information on this form is true and accurate to the best of your
    knowledge.

    Printed name of employer Title

    Employer’s signature (required of hiring employer) Date (required)

    Printed name of person submitting packet Print job title and business or firm name

    Submitter’s signature (required) Date (required) Phone number

    *For more information about the Preferred Worker Program, go to www.Lni.wa.gov/PreferredWorker


    Important: New eligibility requirements began on January 1, 2016. To view online, search RCW 51.32.095(4)

    F280-060-000 Preferred Worker Request 08-2016 Index: 2PWP

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