General Contact Form

WA State L&I Ergonomics or Assistive Technology Referral

V2 WA State L&I Ergonomics or Assistive Technology Referral

Worker Name

Claim Number

Date of Request

Job Goal

Service Requested

Pre-Job Modication Eval

Job Modification Eval

Vocational Services

800 Vocational Recovery

810 Assessment

830 Plan Development

840 Plan Implementation

Self-Insured (Must attach authorization letter from CM with IW name/claim number below)

Injured Worker Phone #

Injured Worker Address

DOI

DOB

Claim Manager

Claim Manager Phone

CM Email

Is the Claim State Fund?

Yes

No

Bill Payer

Bill Payer Phone

Bill Payer Address

Bill Payer Email

VRC Name

VRC Phone #

Assigned VOC Provider #

Referral ID

Attorney Name

Attorney Phone

Contact for Scheduling

Worker

Employer

Attorney

If onsite; Employer Contact Name:

Site to be Evaluated Address:

Phone:

Accepted Diagnostic Code(s)/Descriptions and Denied Conditions

Physical Restrictions

Equipment Already Suggested

Comments / Additional Info

Upload Document (Job Analysis, Limitations, etc.)

Choose File

Upload 2nd Document (Job Analysis, Limitations, etc.)

Choose File

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General Contact Form

WA State L&I Ergonomics or Assistive Technology Referral

Voice Activated Software Training Bid Request