Transitional WorkGRANT$-EZ For small business - It’s 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 correct. ___________________________________________________________________________________________________ Authorized employer signature and title Date signed Fax your application to (614) 621-1118. Please complete and total BWC’s accredited transitional work developer’s invoice amounts for sections III through VI. E-mail your applocation to TWGFeed@bwc.state.oh.us. Section III $ _____________ Section IV $ _____________ Mail your completed application to: Ohio Bureau of Workers’ Compensation Transitional WorkGRANT$-EZ 30 W. Spring St., 22nd floor Columbus, OH 43215-2256 Section V $ _____________ Section VI $ _____________ Total $ _____________ 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$-EZ Reimbursement Request (TWG-EZ-100) with sections I-VI completed, and the supporting materials, including the BWC-accredited transitional work developer’s invoice and the Transitional WorkGRANT$-EZ Agreement (TWG-EZ-110). BWC’s Transitional WorkGRANT$ review team will evaluate your application. Thank you for investing in your company’s 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 and 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 companies.) Date signed February 2004 TWG-EZ-105 American LegalNet, Inc. www.USCourtForms.com Section III Policies and procedures - Employers may hire a BWC-accredited transitional work developer to complete and customize the program’s policies and procedures. Employers may use BWC’s model of sample written policies that are available on BWC’s Web site ohiobwc.com. J Copy of the policies and procedures J Transitional work developer’s invoice J BWC’s model of written policies _________________________________________________________________________________________________________________________________ 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 employer with a list of local community health-care services where employees may receive emergency care, urgent medical treatment or have follow-up physician and specialist visits, and rehabilitation services. J Copy of the community health-care provider list J Transitional work developer’s 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 company’s initial or basic transitional work training that meets the following requirements: J Written policies are discussed with employees prior to starting a transitional work program; J Every employee receives the written policies and have an opportunity to read them and have their questions answered; J The transitional work developer supplies educational modules or packets for new-employee orientation and refresher training. The employer ensures the following educational requirements are met: I Training is provided to new employees within six weeks of employment; I In subsequent years, refresher training is provided to all employees; J Copy of course material and/or educational modules and the attendance sheet; J Transitional work developer’s 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 therapist; licensed occupational therapist; certified disability management specialist; certified vocational evaluator; certified case manager; certified occupational health nurse; certified rehabilitation registered nurse; certified professional ergonomist; certified safety professional with an ergonomics specialist designation and a certified industrial ergonomist; are required to perform job analysis (es). Each job analysis must be signed by the servicing provider and credentials specified. Creation of job banks as transitional job tasks are permitted only when prior approved by BWC. J List of job classifications J List of jobs analysis(es) performed J One sample job analysis with a summary sheet J Job analysis(es) invoice _________________________________________________________________________________________________________________________________ Authorized professional signature Date signed Statement of MCO involvement with employer Your answer for this section will not affect the determination of your grant. The MCO actively either encouraged our organization to apply for a BWC Transitional WorkGRANT$-EZ or referred our organization to a BWC-accredited transitional work developer. J Yes J No The MCO participated with our organization and the transitional work developer, physically attended one or more meetings, in creating the transitional work program. J Yes J No _________________________________________________________________________________________________________________________________ Authorized employer signature and title Date signed _________________________________________________________________________________________________________________________________ Transitional work developer signature Date signed American LegalNet, Inc. www.USCourtForms.com