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Transitional Workgrant EZ Reimbursement Request TWG-EZ-105 - Ohio
| Transitional Workgrant EZ Reimbursement Request Form. This is a Ohio form and can be used in Employers Workers Comp . |
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Transitional WorkGRANT$-EZ For small business - Its easy Reimbursement Request Employer information ________________________________________________________________________ __________________________ Employer name (DBA) ________________________________________________________________________ ___________________________ Contact name Title BWC policy number ________________________________________________________________________ ___________________________ Employer address _____________________________________( )___________________ ___( )________________________ Employer e-mail address Fax number Telephone number ________________________________________________________________________ ___________________________ City State ZIP code ________________________________________________________________________ ___________________________ Managed care organization (MCO) Number of employees To the best of my knowledge, the information submitted on this form is co rrect. ________________________________________________________________________ ___________________________ Authorized employer signature and title Date signed Please complete and total BWCs accredited transitional work Fax your application to (614) 621-1118. developers invoice amounts for sections III through VI. Section III $ _____________ E-mail your applocation to TWGFeed@bwc.state.oh.us. Section IV $ _____________ Section V $ _____________ Mail your completed application to: Ohio Bureau of Workers Compensation Section VI $ _____________ Transitional WorkGRANT$-EZ Total $ _____________ 30 W. Spring St., 22nd floor Columbus, OH 43215-2256 BWC will pay $160 for each approved job analysis. Transitional WorkGRANT$-EZ An eligible company may quality for a $ 2,600 grant. Instructions: Please type or print clearly. When you submit the initial application, include the Transitional WorkGRANT$-EZ Reimbursement Request (TWG-EZ-100) with sections I-VI completed, and the supporting materia ls, including the BWC-accredited transitional work developers invoice and the Transitional WorkGRANT$-EZ Agreement (TWG-EZ-110). BWCs Transitional WorkGRANT$ review team will evaluate your application. Thank you for investing in your companys most valuable resource - your employees. Section I Company description Have a joint meeting with BWC and your MCO to discuss your company s workers compensation program. Your BWC-accredited transitional work developer may attend. ________________________________________________________________________ _________________________________________________________ BWC representative signature and title Date signed ________________________________________________________________________ _________________________________________________________ MCO representative signature and title Date signed Section II Employee and union buy-in Select an employee and/or union representative to provide input an d act on behalf of your employees and/or union workers. The employee represents non-union employees while the union representative advocates for union workers. ________________________________________________________________________ _________________________________________________________ Employee representative signature and title Date signed ________________________________________________________________________ _________________________________________________________ Union representative signature and title (Applies only to unionized com panies.) Date signed February 2004 TWG-EZ-105 American LegalNet, Inc. www.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 2Section III Policies and procedures - Employers may hire a BWC-accredited transitional work developer to com plete and customize the programspolicies and procedures. Employers may use BWCs model of sample written policies that are available on BWCs Web site ohiobwc.com. Copy of the policies and procedures BWCs model of written policies Transitional work developers invoice ________________________________________________________________________ _________________________________________________________Transitional work developer (print name) E-mail address and BWC-accreditation number ________________________________________________________________________ _________________________________________________________Signature Date signed Section IV Community health-care providers - A BWC-accredited transitional work developer will provide the employe r with a list of localcommunity health-care services where employees may receive emergency car e, urgent medical treatment or have follow-up physicianand specialist visits, and rehabilitation services. Copy of the community health-care provider list Transitional work developers invoice ________________________________________________________________________ _________________________________________________________Transitional work developer (print name) E-mail address and BWC-accreditation number ________________________________________________________________________ _________________________________________________________Signature Date signed Section V Training for company owner and employees A BWC-accredited transitional work developer must provide your com panys initialor basic transitional work training that meets the following requirement s: Written policies are discussed with employees prior to starting a transit ional work program; Every employee receives the written policies and have an opportunity to read them and have their questions answered; The transitional work developer supplies educational modules or packe ts for new-employee orientation and refresher training. The employer ensures the following educational requirements are met: Training is provided to new employees within six weeks of employment; In subsequent years, refresher training is provided to all employees; Copy of course material and/or educational modules and the attendance sheet; Transitional work developers invoice. ________________________________________________________________________ _________________________________________________________Transitional work developer (print name) E-mail address and BWC-accreditation number ________________________________________________________________________ _________________________________________________________Signature Date signed Section VI Job analysis Professionals with the following credentials: licensed physical the rapist; licensed occupational therapist; certified disabi
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