Notice Of Closure Worksheet {2807}

Insert name, address, and phone number of insurer: Notice of Closure Worksheet WCD file no.: 1 Workers legal name (first, m.i., last): Date of injury: Type of order: No additional PPD Prior award of disability considered First closure date: SSN: Prior awards of PPD: Date: Value: Date: Value: Other claims? Insurer: No: Open? Yes No Insurers claim no.: Insurer: No: Open? Yes No Authorized Authorized Authorized Authorized 2 Time loss from through Time loss from through Currently working? Yes No TTD TPD TTD TPD Last RTW date: TTD TPD TTD TPD ATP TTD TPD TTD TPD Begin date: TTD TPD TTD TPD ATP end date: TTD TPD TTD TPD Exam/report date: 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 regular work date: Treatment letter sent date: Worker response received date: Date extent of PPD established: Impairment Social/vocational factors 3 4 (Show applicable rules/conversions/computations below) Work Status Regular Modified Amputation Opposition Working: Yes No Yes No Yes No Yes No Range of motion Released: Range Impact Instability DOB: Age: (0-1): Hearing loss (S-5/S-6) Formal education: (0-1): Prosthetic implant Job-at-injury DOT(s): 5-year high SVP DOT(s): Sensory change SVP..(1-4): Surgery Age and education total:. Shortened member Adaptability Weakness 5-year high strength DOT(s): Visual loss (S-3/S-4) Strength code: Chronic condition/ BFC: to RFC: (1-7): repetitive use Age/Ed: X Adapt: Other Impairment (from Section 3):.... % Closing exam: Date: By: % Sum equals disability: ... Primary part Secondary Scheduled/ Total Total Total Net change 5 (code) part (code) unscheduled percent degrees dollars Percent Degrees Dollars Prepared by: Print name/title: D/E operator: NOTE TO WORKER: This worksheet was used to calculate benefits shown on the attached Notice of Closure. This worksheet is not a legal order and is not subject to appeal. If you have questions about how your benefits were calculated, contact the insurer at the address or phone number printed on the front of your Notice of Closure. Additional help is available at the phone numbers listed on the back of your Notice of Closure. <<<<<<<<<********>>>>>>>>>>>>> 2 440-2807 (4/03/DCBS/WCD/WEB) Completion Instructions (Not all data fields are described.) Section 1 Section 4 Type of order: Select from Examples of formatted language in Complete when considering permanent loss of earning capacity numeric order by order type, attached to Bulletin 139. (unscheduled disability) according to the provisions of ORS No additional PPD: Check if PPD has been previously ordered in 656.214(5), 656.726(3)(f) and OAR 436-035. this claim and this notice grants no additional permanent Work status: Note: Do not complete the remainder of Section 4 disability. if the criteria in ORS 656.726(3)(f) have been met. Prior award of disability considered: Check if PPD has been Range impact for age is determined pursuant to OAR 436-035- ordered in another Oregon workers compensation claim for the 0290. same body part or condition and the prior PPD has been Range impact for education is determined pursuant to OAR considered in the calculations of PPD in this Notice of Closure, 436-035-0300. pursuant to OAR 436-035-0007(6). DOT means the Dictionary of Occupational Titles, a First closure date: Enter the first valid closure date for this claim. publication of the U.S. Department of Labor, Fourth Edition Enter the word "NOW" if this is the first closure. Enter the date of Revised 1991. injury if the claim was in an accepted non-disabling status for SVP means specific vocational preparation. Range impact more than one year. values are in OAR 436-035-0300. Prior awards of PPD: Enter the date(s) and value(s) in dollars of Five-year high strength DOT(s): Enter the DOT(s) code(s) any prior awards of permanent disability in either this claim or with the highest strength requirement and enter the strength other Oregon workers compensation claims. code assigned by the DOT to that job. BFC means base functional capacity. See OAR 436-035- Section 2 0310. RFC means residual functional capacity. See OAR 436-035- Time loss: Enter the dates of each time-loss period in the current 0310. opening of the claim, whether or not temporary disability Sum equals disability: Add the result of the social/vocational payments were made. If no temporary disability is authorized, factoring and impairment computations to derive the total enter the word "NONE." unscheduled disability. ATP (authorized training program): Check here if this Notice of Closure is being processed subsequent to the worker ending an Section 5 ATP (either by completion or termination). Enter the dates the ATP began and ended and the date of the most recent closing Primary part (code): Enter the name and code of each body medical report that established the workers impairment and/or part. (See the Body Part Coding Chart attached to this bulletin.) medically stationary status. Note right (R) or left (L) or both (B) if applicable. Date claim qualified for closure: Provide this date only if the Secondary part (code): In cases that involve more than one claim qualified for closure when the worker was not medically unscheduled body part, note the body part/area that receives the stationary pursuant to OAR 436-030-0034. majority of the award in "Primary part" and the other Computed per OAR 436-030- : Provide the administrative unscheduled body parts in a like manner in "Secondary part." rule by which the workers medically stationary date or the date Scheduled/unscheduled: Show whether the disability being the claim qualified for closure was established. awarded is for a scheduled or unscheduled body part as follows: U-1 All unscheduled cases Section 3 S-1 All scheduled cases not described below S-2 Loss of opposition Check the boxes that apply to those impairment factors included in S-3 Loss of vision, right or left eye the computation of disability pursuant to OAR 436-035. Enter the S-4 Binocular vision loss body parts involved, including references to right (R) or left (L) or S-5 Loss of hearing, right or left ear both (B), if appropriate, beside the conditions indicated. Note the S-6 Binaural hearing loss applicable rules and computations that result in final impair- ment(s). Total percent/degrees/dollars: Enter amounts. Net change: If the disabilit