Oregon > Workers Comp > Vocational Rehabilitation
Request For Administrative Approval 1084 - Oregon
| Request For Administrative Approval Form. This is a Oregon form and can be used in Vocational Rehabilitation Workers Comp . |
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Submit to: Department of Consumer & Business Services Workers' Compensation Division 350 Winter St. NE P.O. Box 14480 Salem, Oregon 97309-0405 Date: Counselor name: Phone: Vocational rehabilitation organization (name, city): Request for Administrative Approval Worker: WCD file no.: Insurer: Claim no.: DOI: Reason for request (check one): Extension of training beyond 16 months; director's approval required by ORS 656.340(12) Other (explain): Approval requested for: 1. Extension of training beyond 16 months due to: a) b) Exceptional disability Exceptional loss of earning capacity Explain what you are requesting and why it is necessary. Attach all medical and vocational reports or other information that supports this request that you have not already submitted to WCD. 2. Director's Waiver (OAR 436-120-0003(5)) 3. Other: INSURER APPROVAL: Insurer signature Date Phone: WCD APPROVAL: WCD signature Date For WCD use only 440-1084 (12/07/DCBS/WCD/WEB) 1084 American LegalNet, Inc. www.FormsWorkflow.com
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