Fill and Sign the Notice of Closure Worksheet Injury Prior to January 1 2005 Oregon Form

Insert name, address, and phone number of insurer:       Notice of Closure Worksheet (Dates of injury prior to 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 (S-5/S-6) Prosthetic implant Sensory change Surgery Change of length Strength loss Visual loss (S-3/S-4) 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: unscheduled (%)       (1-7):       Higher adaptability value: ……..……….……       Total social-vocational value Age/ed    X Adapt    = Value ….. …    Unscheduled impairment (Section 4): ………….…     % Total percent unscheduled disability: ………….…     % 6 Primary part (code) Secondary part (code) Scheduled/ unscheduled Total percent Total degrees Total dollars Net change Percent Degrees 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. 440-2807 (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. Section 5 Do not complete Section 5 if the worker:  Has no impairment, or  Has impairment and o Returned to regular work, o Was released to regular work, but failed to return for reasons within their control, or o Was released to regular work, but was terminated for reasons not related to the injury. Age and education: Age : See OAR 436-035-0012 to determine value. Formal 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 DOT codes for the job with the highest strength demand. 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 the percent of unscheduled 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. Total 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 Primary part (code) : Enter the name and code of each body part. (See the Body Part Coding Chart on the division’s Web site: www.wcd.oregon.gov/policy/bulletins/ab_index.html.) Note “right” (R) or “left” (L) or “both” (B) if applicable. Secondary part (code) : In cases that involve more than one unscheduled body part, note the body part/area code that receives the majority of the award in “Primary part” and the other unscheduled body part codes in a like manner in “Secondary part.” Scheduled/unscheduled : Show whether the disability being awarded is for a scheduled or unscheduled body part as follows: U-1 All unscheduled cases S-1 All scheduled cases not described below S-2 Loss of opposition S-3 Loss of vision, right or left eye S-4 Binocular vision loss S-5 Loss of hearing, right or left ear S-6 Binaural hearing loss Total percent : If impairment is in an unscheduled body part/area, add percentage of impairment (Section 4) to value resulting from social-vocational factoring (Section 5) and insert total. If impairment is to scheduled body part/area, insert percentage of impairment only. Total degrees : Enter matching degree values for each body part using the “Conversion from percentage to degrees of disability” chart on the division’s Web site: http://wcd.oregon.gov/forms/Pages/bulletins.aspx . Total dollars : Multiply number of degrees by dollars per degree from rate schedule issued with Bulletin 111 based on date of injury and type of disability (scheduled or unscheduled) and enter. Net change : If the disability computed under this claim closure is greater than or less than the most recent total award(s) in this claim , show percent, degrees, and dollar amount of increase or decrease using “+” or “-” (e xample: +22.40 degrees is an increase of 22.40 degrees, while -22.40 degrees is a decrease of 22.40 degrees). 440-2807 (01/10/DCBS/WCD/WEB)