Insert name, address, and phone number of insurer: Notice of Closure Worksheet (Dates of injury prior to 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 ATP begin date: Authorized through Value: TTD TTD TTD No OR 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 (Show applicable body part code/rules/conversions/computations below) 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): Social/vocational factors 5 Age and education By: 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 (S-5/S-6) ………………… Total age/ed value ….………………………….………..... Prosthetic implant Adaptability Sensory change 5-year high strength DOT(s): Strength code: BFC: to RFC: Adaptability scale: unscheduled (%) Surgery Change of length Strength loss (1-7): (1-7): Higher adaptability value: ………………………….…… Visual loss (S-3/S-4) Social-vocational value Chronic condition Age/ed Other 6 Primary part (code) Prepared by: X Adapt = Unscheduled impairment (from Section 4): Secondary part (code) Scheduled/ unscheduled Total percent Print name/title: Total degrees Total dollars Value …..… ………….… % % Sum equals disability: ………….… Net change Percent Degrees Dollars 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. 440-2807 (2/06/DCBS/WCD/WEB) American LegalNet, Inc. www.FormsWorkflow.com Completion Instructions (Not all data fields are described.) Section 1 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. 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 4 Enter date of exam and name of physician performing the closing exam from which objective findings of impairment are being derived. Check the boxes that apply to those impairment factors included in the computation of disability under OAR 436-035. Enter 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, show computations for each and identify by body part code. Section 5 Work status: Do not complete Section 5 if the worker has unscheduled impairment and 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.” Range impact for age: Determined according to OAR 436-0350012. Range impact for education: Determined according to OAR 436035-0012. 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 percentage of unscheduled 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 socialvocational value. Section 6 Primary part (code): Enter the name and code of each body part. (See the Body Part Coding Chart attached to Bulletin 139.) Note “right” (R) or “left” (L) or “both” (B) if applicable. Secondary part (code): In cases that involve more than one unscheduled body part, note the body part/area code that receives the majority of the award in "Primary part" and the other unscheduled body part code(s) in a like manner in "Secondary part." Scheduled/unscheduled: Show whether the disability being awarded is for a scheduled or unscheduled body part as follows: U-1 All unscheduled cases S-1 All scheduled cases not described below S-2 Loss of opposition S-3 Loss of vision, right or left eye S-4 Binocular vision loss S-5 Loss of hearing, right or left ear S-6 Binaural hearing loss Total percent: If impairment is to unscheduled body part/area, add percentage of impairment to value resulting from social-vocational factoring (Section 5) and insert total. If impairment is to scheduled body part/area, insert percentage of impairment only. Total degrees: Using “Conversion from percentage to degrees of disability” chart attached to Bulletin 139, enter correlating degree value(s) for each body part. Total dollars: Multiply number of degrees by applicable dollars per degree from rate schedule issued with Bulletin 111 based on date of injury and type of disability (scheduled/unscheduled) and enter. Net change: If the disability computed under this claim closure is greater than or less than the most recent total award(s) in this claim, show percent, degrees, and dollar amount of increase or decrease using "+" or "-" (Example: +22.40 degrees is an increase of 22.40 degrees, while -22.40 degrees is a decrease of 22.40 degrees). 440-2807 (2/06/DCBS/WCD/WEB) American LegalNet, Inc. www.FormsWorkflow.com