Minnesota Department of Labor and Industry Workers’ Compensation Division www.dli.mn.gov/wc/wcforms,asp Report of Work Ability See Instructions of Reverse Side R W PRINT IN INK or TYPE Enter dates in MM/DD/YYYY format. 0 1 DO NOT USE THIS SPACE This form must be provided to the employee. (Minn. Rules 5221.0410,l subd. 6) NOTICE TO EMPLOYEE: YOU MUST PROMPTLY PROVIDE A COPY OF THIS REPORT TO YOUR EMPLOYER OR WORKERS’ COMPENSATION INSURER, AND QUALIFIED REHABILITATION CONSULTANT IF YOU HAVE ONE. WID or SSN DATE OF INJURY EMPLOYEE EMPLOYER INSURER/SELF-INSURER-TPA INSURER CLAIM NUMBER Date of most recent examination by this office Select the appropriate option(s) below and fill in the applicable dates. 1. Employee is able to work without restrictions as of 2. (date) Employee is able to work with restrictions, from (date) to (date) The restrictions are: 3. Employee is unable to work from The next scheduled visit is: (date) to (date) as needed OR NAME (Type or Print) SIGNATURE ADDRESS STATE CITY STATE ZIP CODE DEGREE LICENSE #/REGISTRATION # PHONE # (include area code) DATE SIGNED American LegalNet, Inc. www.FormsWorkFlow.com MN RW01 (7/10) INSTRUCTIONS FOR COMPLETING REPORT OF WORK ABILITY Each health care provider directing the course of treatment for an employee who alleges to have incurred an injury on the job must complete a Report of Work Ability within 10 days of a request for a Report of Work Ability from the insurer, or at the applicable interval (Minn. Rules 5221.0410, subp. 6): 1. every visit if visits are less frequent that one every two weeks; 2. every 2 weeks if visits are more frequent than once every two weeks, unless work restrictions change sooner; and 3. upon expiration of the ending or review date of the restrictions specified in a previous Report of Work Ability. The Report of Work Ability must either be on this form or in a report that contains the same information. The Report of Work Ability must: • Identify the employee by name, WID or social security number, and date of injury. • Identify the employer at the time of the employee’s claimed work injury. • If known, identify the workers’ compensation insurer at the time of the claimed injury, or the workers’ compensation third-party administrator. Also indicate this workers’ compensation payer’s claim number. • Indicate the date of the most recent examination by this office. The Report of Work Ability should be completed based on this evaluation. • Identify the appropriate option which best describes the employee’s current ability to work by checking box 1, 2, or 3. 1. If the employee is able to work without restrictions, fill in the beginning date. 2. If the employee is able to work with restrictions, fill in the date any restriction of work activity is to begin and the anticipated ending or review date. Describe any restrictions in functional terms (e.g., employee can lift up to 20 pounds, 15 times per hour; should have 10 minute break every hour). 3. If the employee is unable to work at all, fill in the date the restriction of work activity is to begin and the anticipated ending or review date. • Indicate the date of the next scheduled visit or indicate that additional visits will be scheduled as needed. • Identify the health care provider completing the report by name, professional degree, license or registration number, address and phone number. • Include the signature of the health care provider and date of the report. The health care provider must provide the Report of Work Ability to the employee and place a copy in the medical record. If you have questions, please call the claim representative or the Department of Labor and Industry, Workers’ Compensation Division at (651) 284-5030 or 1-800-342-5354. This material can be made available in different forms, such as large print, Braille or on a tape. To request, call (651) 284-5030 or 1-800-342-5354 (DIAL-DLI) Voice or TDD (651) 297-4198. ANY PERSON WHO, WITH INTENT TO DEFRAUD, RECEIVES WORKERS’ COMPENSATION BENEFITS TO WHICH THE PERSON IS NOT ENTITLED BY KNOWINGLY MISREPRESENTING, MISSTATING, OR FAILING TO DISCLOSE ANY MATERIAL FACT IS GUILTY OF THEFT AND SHALL BE SENTENCED PURSUANT TO SECTION 609.52, SUBDIVISION 3. American LegalNet, Inc. www.FormsWorkFlow.com