OREGON Preferred Worker Program Worksite Modification Agreement (for Employer at Injury – limited to $2,500) Workers’ Compensation Division If you have questions or need assistance completing this agreement, please contact the Preferred Worker Program in Salem, (503) 947-7588; toll-free in Oregon, (800) 445-3948; fax, (503) 947-7581; TTY, (503) 9477993; in Medford, call (541) 776-6032 or (800) 696-7161; fax, (541) 776-6246. For worksite modifications costing more than $2,500, contact the Preferred Worker Program for development of a special contract. Employer Worker Legal name: Name: Complete address: Doing business as: Complete address: (Street/P.O. box, city, state, ZIP) (Street/P.O. box, city, state, ZIP) Phone: Phone: Date of injury: Contact person(s): Federal tax ID no: Date worker started job: Job at the time of injury: This job (check one): New job Modified job at injury Worker’s job title: The Workers’ Compensation Division and employer agree to the following: 1) The Workers’ Compensation Division will: a) Provide worksite modification assistance in accordance with Oregon Administrative Rules Chapter 436, Division 110. b) Reserve the right to visit the worksite and to inspect and copy employer records to verify employment of the worker, and otherwise determine compliance with this agreement. c) Provide an Authorization for Payment, Form 2344, or reimburse costs for worksite modifications. d) Determine whether modification items become the property of employer, worker, or leasing company’s client. e) Send the employer a copy of this agreement upon approval. f) End this agreement at any time by written notice to the employer if the division determines, at its sole discretion, that the employer has not complied with the terms of this agreement or with state or federal law governing this employment. 2) The employer will: a) Maintain Oregon workers’ compensation insurance coverage as long as the employer is a subject employer as defined by ORS 656.023. b) Employ the worker as a (job title) according to the terms of the employer’s business practices, policies, and agreements affecting all other employees of the employer. c) Notify the division if the worker’s employment ends prior to the agreement’s end date. d) Use an Authorization for Payment, Form 2344, to purchase worksite modification(s), when applicable, or send the division a legible copy of an invoice or receipt that indicates payment has been made. All reimbursement requests must be submitted within one year of the agreement end date. e) Hold harmless all public entities within the limitations of ORS 30.260 et seq. or Article XI, Sections 7 and 10 of the Oregon Constitution, the State of Oregon, the department, its officers, agents, employees, and assignees, from any claims, suits, or actions of any nature resulting from or arising out of the activities of the worker or employer or their designees, agents, or employees under this agreement. (OVER) 440-2969 (7/05/DCBS/WCD/WEB) American LegalNet, Inc. www.USCourtForms.com f) g) h) Repay all costs incurred by the division under this agreement, including all legal costs and attorney fees, if the division finds the employer falsely obtained re-employment assistance or if the division subsequently prevails in any legal action against the employer arising out of this agreement. Agree that the worksite modification(s) described below will be purchased and installed in the worksite(s) and be available for the worker’s use as long as the worker is employed by the employer in work for which the modification is necessary. Agree that the modification item(s) will not be removed from the worksite without the division’s prior written approval, so long as the worker is employed by the employer in work for which the modification is necessary. PROGRAM USE ONLY Worksite modification item(s) Cost* Worker Property of: Employer Other 1. 2. 3. 4. 5. 6. 7. Total cost: * Three competitive quotes are required for chairs costing more than $1,000. Items costing more than $2,500 require a separate agreement. This agreement is not valid until signed by an authorized representative of both parties. To the best of my knowledge, this job as modified is within the worker’s injury-caused restrictions. I understand the division will not directly purchase or otherwise assume responsibility for modification items. I understand the division assumes no liability for repairing or replacing damaged or lost items, and has no liability for injuries or damages caused by any worksite modification purchase. Employer signature Date Send to: Preferred Worker Program, 350 Winter St. NE, P.O. Box 14480, Salem, OR 97309-0405 DIVISION USE ONLY Maximum approved under this agreement Effective date: Data entry $ End date: Worker’s WCD No. Certified true, accurate, correct, and an appropriate expenditure for this program. Program approval Date WCD Reg. No. 440-2969 (7/05/DCBS/WCD/WEB) American LegalNet, Inc. www.USCourtForms.com