Insert name, address, and phone number of insurer: Notice of Closure Worksheet (Dates of injury on or after January 1, 2005) 1 WCD file no.: Worker’s legal name (first, m.i., last): Date of birth: No additional PPD Type of order: Prior awards of PPD: Date: Other claims? 2 First closure date: Value: Time loss Authorized through Value: TTD TTD TTD No OR ATP begin date: Authorized from Time loss Dates: Date claim qualified for closure: Report dated: Failed exam date: Worker response received date: Authorized from Time loss Authorized through TPD TPD TPD Per OAR 436-030A.P. concurrence? Yes No Dated: Released to regular work date: Date extent of PPD established: Exam/report date: Impairment Social/vocational factors 5 (Show applicable body part code/rules/conversions/computations below) By: Closing exam: Date: No TTD TTD TTD TPD TPD TPD ATP end date: Insurer’s claim no.: Open? Yes Authorized through No: Authorized from SSN: Prior PPD award considered Date: Insurer: TTD TPD TTD TPD TTD TPD Three-day waiting period: Yes Med-stat date: Per A.P. report Per IME Last exam/treatment date: Treatment letter sent date: 3 4 Date of injury: Denial date(s): Age and education Range (0-1): Amputation Age: Opposition Formal education: Job-at-injury DOT(s): 5-year high SVP DOT(s): SVP………………………………………... Impact (0-1): (1-4): Range of motion Instability Hearing loss ………………… Total age/ed value ….………………………….………..... Prosthetic implant Adaptability Sensory change 5-year high strength DOT(s): Strength code: BFC: to RFC: Adaptability scale: whole person (%) Surgery Change of length Strength loss (1-7): (1-7): Higher adaptability value: ………………………….…… Visual loss Whole person Social-vocational value Chronic condition Other 6 7 8 9 Age/ed % X Adapt = Value ……… Impairment calculation: Whole person (%) X 100 X (SAWW) $ = Impairment benefit: ………………………………………... $ Work disability calculation: Whole person (%) Total PPD calculation: + Soc-voc value $ Impairment benefit Subsequent change of award: Prior award of PPD in dollars Prepared by: X 150 X (Worker AWW) + Work disability benefit $ = Work disability benefit: $ = Total PPD award: ……………………. $ Net change of award in dollars 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. 440-2807a (2/06/DCBS/WCD/WEB) American LegalNet, Inc. www.FormsWorkflow.com Completion Instructions (Not all data fields are described.) Section 1 Section 5 Denial dates: Enter only dates of denials issued and still within the appeal period, final by operation of law, or currently under appeal. Type of order: Select from “Examples of formatted language in numeric order by order type,” attached to Bulletin 139. No additional PPD: Check if: 1) PPD has been previously ordered in this claim, and 2) this notice grants no additional permanent disability. First closure date: Enter the first valid closure date for this claim. Enter the word "NOW" if this is the first closure. Enter the date of injury if the claim was in accepted non-disabling status for more than one year. Prior PPD award considered: Check if PPD has been ordered in another Oregon workers' compensation claim for the same body part or condition and the prior PPD has been considered in the calculations of PPD in this Notice of Closure, according to OAR 436-035-0015. Prior awards of PPD: Enter the date(s) and value(s) in dollars of any prior awards of permanent disability in this claim or other Oregon workers’ compensation claims. Work status: Dates of injury January 1, 2005 through December 31, 2005: Do not complete Section 5 if any of these criteria (ORS 656.726(4)(f)(E)) have been met. • “Worker has returned to regular work at job at injury; • “Worker has been released to return to regular work at job at injury and the job is available, but worker fails or refuses to return to the job; or • “Worker has been released to return to regular work at job at injury, but worker’s employment is terminated for cause unrelated to the injury.” Dates of injury on or after January 1, 2006: Do not complete Section 5 if the worker has been released by his or her doctor to return to regular work or has returned to regular work. Range impact for age: Determined according to OAR 436-0350012. Range impact for education: Determined according to OAR 436-035-0012. DOT: The Dictionary of Occupational Titles, a publication of the U.S. Department of Labor, Fourth Edition, Revised 1991. SVP: “Specific vocational preparation.” Enter impact value from OAR 436-035-0012. Five-year high strength DOT(s): Enter the DOT code(s) with the highest strength requirement and the strength code assigned by the DOT to that job. BFC: “Base functional capacity.” See OAR 436-035-0012 to choose value to enter. RFC: “Residual functional capacity.” See OAR 436-035-0012 to choose value to enter. Adaptability: Using the scale in OAR 436-035-0012(15), enter the whole person impairment and select the correlating value. Higher adaptability value: Compare the two adaptability values and enter the higher value. Social-vocational value: Multiply the result of the “age/ed” factoring and “adaptability” computations to derive the total social-vocational value. Section 2 Time loss: Enter the dates of each time-loss period in the current opening of the claim, whether or not temporary disability payments were made. If no temporary disability is authorized, enter the word "NONE." Date claim qualified for closure: Provide this date only if the claim qualified for closure when the worker was not medically stationary under OAR 436-030-0034. Computed per OAR 436-030: Cite the administrative rule by which the worker's medically stationary date or the date the claim qualified for closure was established. Section 3 ATP (authorized training program): If this Notice of Closure is being processed subsequent to the worker ending an ATP (either by completion or termination), enter the dates the ATP began and ended and the date of the most recent closing medical report that established the worker's impairment and/or medically stationary status. Section 6 Enter the whole person impairment percentage (from Section 4). Multiply by 100; enter the SAWW and multiply to determine the impairment benefit in dollars. Section 4 Section 7 Enter date of exam and name of physician performing the closing exam from which objective findings of impairment are being derived. Enter the whole person impairment percentage (from Section 4) and the social-vocational value (from Section 5) and add; multiply by 150. Enter the worker’s average weekly wage. Multiply the result of previous calculations in this section by the worker’s AWW to determine the work disability benefit in dollars. Check the boxes that apply to those impairment factors included in the computation of disability under OAR 436-035. Show the body parts involved, including references to right (R) or left (L) or both (B), if appropriate, beside the conditions indicated. Note the applicable rules and computations that result in final impairment(s). If more than one body part has permanent disability for which benefits are being awarded, combine individual whole person percentages in descending order to reach a whole person value and enter the percentage in the box. Section 8 Enter the impairment benefit in dollars (from Section 6) and the work disability benefit in dollars (from Section 7) and add. Section 9 If a prior award of permanent disability in this claim is being modified by this order, enter the dollar value of the prior award and the net change (in dollars) resulting from this notice. 440-2807a (2/06/DCBS/WCD/WEB) American LegalNet, Inc. www.FormsWorkflow.com