Fill and Sign the Notice of Closure Worksheet Injury on or After January 1 2005 Oregon Form

Insert name, address, and phone number of insurer:       Notice of Closure Worksheet (Dates of injury on or after Jan. 1, 2005) 1 Worker’s legal name (first, m.i., last):       WCD file no.:       Date of birth:       Denial date(s):       Date of injury:       Type of notice:       No additional PPD First closure date:       Prior PPD award considered Prior awards of PPD: Date:       Value:       Date:       Value:       Insurer’s claim no.:       Other claims? Insurer:       No:       Open? Yes No 2 Time loss Authorized from Authorized through Time loss Authorized from Authorized through Time loss Authorized fromAuthorized through TTD TPD             TTD TPD             TTD TPD             TTD TPD             TTD TPD             TTD TPD             TTD TPD             TTD TPD             TTD TPD             Three-day waiting period: Yes No Dates:       Med-stat date:       OR Date claim qualified for closure:       Per OAR 436-030-       Per A.P. report Per IME Report dated:       A.P. concurrence? Yes No Dated:       Last exam/treatment date:       Failed exam date:       Released to regular work date:       Treatment letter sent date:       Worker response received date:       Date extent of PPD established:       3 ATP begin date:       ATP end date:       Exam/report date:       4 Impairment (Show applicable body part code/rules/conversions/computations below) 5 Social/vocational factors Closing exam: Date:       By:       Age and education Range Impact Amputation Opposition Range of motion Instability Hearing loss Prosthetic implant Sensory change Surgery Change of length Strength loss Visual loss Chronic condition Other             Age:       ………………… (0-1):       Formal education:       (0-1):       Job-at-injury DOT(s):             5-year high SVP DOT(s):             SVP………………………………………... (1-4):       Total age/ed value ….………………………….……….....       Adaptability 5-year high strength DOT(s):             Strength code: BFC: to RFC: (1-7):       Adaptability scale: whole person (%)       (1-7):       Higher adaptability value: ………………………….……       Whole person Social-vocational value       % Age/ed   X Adapt   = Value ………    6 Impairment calculation: Whole person (%)       X 100 X (SAWW) $       = Impairment benefit: ………………………………………... $       7 Work disability calculation: Whole person (%)     + Soc-voc value       X 150 X (Worker AWW) $       = Work disability benefit: $       8 Total PPD calculation: Impairment benefit $       + Work disability benefit $       = Total PPD award: ……………………. $       9 Subsequent change of award: Prior award of PPD in dollars $       Net change of award in dollars $       Prepared by:       Print name/title:       D/E operator:       NOTE TO WORKER: The insurer used this worksheet to calculate benefits shown on the attached Notice of Closure (NOC). This worksheet is not a legal order and is not subject to appeal. If you have questions, contact the insurer at the address or phone number on the front of the NOC. You can get more help by calling the phone numbers listed on the back of the NOC. 440-2807a (01/10 /DCBS/WCD/WEB) Completion Instructions (Not all data fields are described.) Section 1 Type of notice: 1100 Fatal without time loss 1101 Fatal with time loss 1120 Unrelated death, time loss, no permanent partial disability 1 121 Unrelated death with time loss/permanent partial disability 1200 Grant of permanent total disability 1222 Closure of an open or reopened claim, TD only 1223 No TD or PPD 1224 Closure following DCBS suspension order, TD only 1315 Rescind prior Notice of Closure (Form 1644r) 1320 Rescind prior Notice of Closure; reissue with TD and PPD (Form 1644) 1321 Rescind prior Notice of Closure; reissue with TD only (Form 1644) 1388 Correcting previous Notice of Closure (Form 1644c) 1701 PTD redetermination; PTD reduced or ended (Form 1644p) 1800 Redetermination after end of authorized training program, PPD unchanged 1801 Redetermination after end of authorized training program, PPD reduction 1802 Redetermination after end of authorized training program, PPD increase 1832 Closure of an open or reopened claim with PPD and with or without TD 1834 Closure following DCBS suspension order, with PPD and with or without TD Section 4 Check the boxes that apply to impairment factors included in computation of disability under OAR 436-035. Enter the body parts involved, including references to right (R) or left (L) or both (B), if appropriate, beside the factors indicated. Note the applicable rules and computations that result in final impairment(s). If more than one body part has rateable permanent disability, show computations for each and identify by body-part code. Combine individual whole person percentages in descending order to reach a whole-person value and enter the percentage in the box. Section 5 Dates of injury Jan. 1, 2005, through Dec. 31, 2005 : Do not complete Section 5 if the worker’s situation meets any of these criteria (ORS 656.726(4)(f)(E)):  Worker has returned to regular work at job at injury;  Worker has been released to return to regular work at job at injury and the job is available, but worker fails or refuses to return to the job; or  Worker has been released to return to regular work at job at injury, but worker’s employment is terminated for cause unrelated to the injury. Dates of injury on or after Jan. 1, 2006 : Do not complete Section 5 if the worker’s doctor released him or her to return to regular work or the worker returned to regular work. Age and education : Age : See OAR 436-035-0012 to determine value. Education : See OAR 436-035-0012 to determine value. DOT : The Dictionary of Occupational Titles , a publication of the U.S. Department of Labor, Fourth Edition, Revised 1991. SVP : “Specific vocational preparation.” Enter impact value from OAR 436-035-0012. Adaptability : Five-year high strength DOT(s) : Enter the DOT codes with the highest strength requirement. Strength code : Enter strength code assigned by DOT to that job. BFC (Base functional capacity) to RFC (Residual functional capacity) : See OAR 436-035-0012 for values. Enter strength capacity codes; compare and enter resulting value. Adaptability : Enter percent of whole-person impairment and select the matching value from the scale in OAR 436-035- 0012(15). Higher adaptability value : Compare the “BFC-to-RFC” value with the “Adaptability” value and enter the higher value. Social-vocational value : Multiply the result of the “age/ed” factor values by the “adaptability” value to get the total social- vocational value. Section 6 Enter the whole-person impairment percentage (from Section 4). Multiply by 100; enter the state’s average weekly wage (SAWW) and multiply to determine the impairment benefit in dollars. Section 7 Enter the whole-person impairment percentage (from Section 4) and the social-vocational value (from Section 5) and add; multiply the total by 150. Enter the worker’s average weekly wage (AWW). Multiply the result of the previous calculations in this section by the worker’s AWW to determine the work disability benefit in dollars. Section 8 Enter the impairment benefit in dollars (from Section 6) and the work disability benefit in dollars (from Section 7) and add. Section 9 If you are modifying a prior award of permanent disability in this claim by this order, enter the dollar value of the prior award and the net change (in dollars) resulting from this notice. 440-2807a (01/10/DCBS/WCD/WEB)