Fill and Sign the Vocational Closure Report Oregon Form

Submit to: Department of Consumer and Business Services Workers’ Compensation Division 350 Winter St. NE P.O. Box 14480 Salem, Oregon 97309-0405 Vocational Closure Report Worker name:       WCD file no.:       DOI:       Insurer:       Claim no.:       1. End of eligibility for vocational services a. Reason (check up to two): Reason Rules that apply OAR 436-120- Code Reason Rules that apply OAR 436-120- Code Suitably employed more than 60 days 0165(1)(b) EM Declined or unavailable for services 0165(1)(h) DS Refused offer of or left suitable job0165(1)(d), (e), and (g) JE Voc assistance won’t resolve unemployment 0165(1)(k) NF Failure to cooperate or misbehavior involving one of the following: Claim disposition agreement 0165(1)(p) DA Participating in light-duty work 0165(1)(f) FC Maximum services 0165(1)(q) MS Refused suitable training site 0165(1)(i) FC New information: 0165(1)(a) Develop or participate in RTW plan 0165(1)(j) FC Not authorized to work in the U.S. UW Fails to notify counselor 0165(1)(j) FC No longer has substantial handicap SH Misrepresented relevant information 0165(1)(l) FC Released to regular work RR Returning property provided by insurer 0165(1)(m) FC Can return to other suitable and available work CW Misused funds 0165(1)(n) FC Other (describe below): OT Harassment, other abuse 0165(1)(o) FC       b. Decision effective date:       c. Return to work. Complete if code checked above includes EM or JE: RTW date:       SOC/DOT code:       RTW weekly* wage: $       Job title:       Employer is: employer at injury employer at aggravation new employer Job type is: regular modified new * To convert an hourly wage to weekly, multiply hourly wage by hours worked per week. To convert a monthly wage to weekly, divide monthly wage by 4.35. 2. End of training a. Did worker complete training? Yes No b. Date training ended:       c. Date Notice of End of Training sent to worker:       3. Return-to-work and rehabilitation providers and costs List providers below. Enter total costs of vocational assistance since the most recent start or restoration of assistance. Do not include costs for eligibility evaluations or temporary disability during training. a. Direct worker purchases under OAR 436-120-0710 (tuition, fees, books, OJT reimbursement, mileage, etc.): $       b. RTW and vocational assistance providers (List in chronological order, with most recent provider last). Organization names: Professional costs:       $             $             $       Signature WCD use only 2800Insurer/provider: Date:       Phone:       440-2800 (1/17/DCBS/WCD/WEB)