Department of and Industries Claims PO Box 44291 Olympia WA ABILITY TO WORK NON-ELIGIBLE ASSESSMENT CLOSING REPORT Do not use a cover or routing sheet Not for use with SAS3 closures Claim #: Worker Name: Claim Unit: Worker Age: Date of Injury: Job at time of injury: Work pattern at time of injury Full time Part time per week: Assigned VRC Name (Printed or typed): Assigned VRC Signature: VRC Phone # and Extension: VRC FAX #: Vocational Firm Provider & Branch #: Report Date: Recommended Outcome Code: Recommended Outcome Code Narrative: Return to Work Date: Name of Employer: Monthly Wages at Date of Injury: Monthly for Return to Work: Job Possibilities the Worker is Qualified for: Was all missing information explained? Yes No WorkSource Visit Date: Job Search Tools Used: Resume Assistance Date: Resume Attached? Yes No Date of Referral: Intake Date: Date Job Analyses(JA) Sent to Attending Physician (AP): Date Job Analyses (JA) Addressed by Attending Physician (AP):
2C. Identify ongoing treatment and the impact on ability to work. 2D. Identify available independent medical examinations (IMEs) and summarize the ability to work opinions. Include IMEs conducted only the worker achieved maximum abilities. Date IME Provider Specialty Opinion regarding ability to work Did AP review the IME? Are AP work restrictions in line with IME? Yes No Yes No No response Yes No Yes No No response VOCATIONAL INFORMATION Address vocational information impacting the worker’s ability to work. 3A. Education Name and Location of High School Graduated? Yes If yes, year: No If no, last grade completed: GED? Yes If yes, year: No school or vocational training: (college, business school, military, OJT, etc.) attended From/To Name/Type/Location Completed Certificate or Degree Issued Major/Subjects Transcripts obtained? Yes No Yes No Yes No Yes No If applicable, explain why transcripts are unavailable. 3B. Identify non-work related activities such as hobbies or volunteer experience(s). Activity/experience Skills acquired 3C. List each position in the work history starting with the oldest. Address any gaps in employment.
5D. JA Previous/Transferable Skills Jobs 5I. Testing Report 5E. Job Mod/Pre-Job Consultation Report 5J. (describe below) Acronym Key AP Attending physician ATW Able to work DOI Date of injury DOT Dictionary of Occupational Titles LMS Labor market survey JA Job analysis JOI Job at time of injury IME Independent medical examination OJT On-the-job training RTW Return to work SNA Services not appropriate SVP Specific vocational preparation time VRC Vocational rehabilitation counselor FCE Functional Capacity Evaluation Instructions Do not include the instructions when submitting your closing report. Do not copy and case notes, progress reports or entire medical reports in sections 1-3. Create additional rows or boxes in the form if needed. Enter N/A if a box does not apply. Remember to provide an explanation when requested information is not obtained. See It is not necessary to attach a Routing or Cover Sheet with the recommendation because the information is included in the index. Cover Page Enter all information requested. Remember to provide an explanation when requested information is not obtained. Return to work date: required for RTW outcomes. Monthly Wages for Return to Work: required for RTW outcomes. WorkSource Visit Date: If unable, please explain why in the space provided. Job Search Tools Used: If unable, please explain why in the space provided. Job Possibilities that the Worker is qualified for: required for all outcomes.