OREGON Preferred Worker Worksite Modification Agreement (Limited to $2,500) Workers’ Compensation Division If you have questions or need further assistance, please contact the Preferred Worker Program in Salem, (503) 947-7588; toll-free in Oregon, (800) 445-3948; fax, (503) 947-7581; TTY, (503) 947-7993. 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: WCD no: (from front of Preferred Worker card) Contact person(s): Job at the time of injury: Federal tax ID no.: Check all that apply: Date worker started job: New employer Employer at time of injury Worker’s job title: New job Modified job at injury The Workers’ Compensation Division (WCD), worker, and employer agree to the following: 1) 2) 3) 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 (AFP) or reimburse costs for worksite modifications. d) Determine, at its own discretion, whether modification items become the property of employer, worker, or leasing company’s client. e) Send the employer and worker a copy of this agreement upon approval. f) End this agreement at any time by written notice to the employer and the worker if WCD determines, at its sole discretion, that the employer or worker has not complied with the terms of this agreement or with state or federal law governing this employment. The worker will: a) Abide by the terms of the employer’s business practices, policies, and agreements generally affecting all other employees of the employer. 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 program if the worker’s employment ends prior to the agreement’s end date. d) Repay part or all of the worksite-modification costs, if determined appropriate by WCD, should the employer enter into negotiation for sale or merger of the business, or enter into bankruptcy or receivership action(s) during the period of this agreement, resulting in the end of the worker’s employment or the sale or removal of the worksite modification from the worker’s use due to such action(s). (OVER) 440-1930 (7/05/DCBS/WCD/WEB) American LegalNet, Inc. www.USCourtForms.com 4) The worker and employer will: a) Use an AFP to purchase worksite modification(s), when applicable, or send WCD a legible copy of an invoice or receipt which indicates the items have been paid. All reimbursement requests must be submitted within one year of the agreement end date. b) 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. c) Repay all costs incurred by WCD under this agreement if WCD finds the employer or worker obtained reemployment program assistance under false pretenses. Repayment may include, at WCD’s sole discretion, all legal costs and attorney fees should WCD prevail in legal action(s), and the return of worksite modification equipment provided by WCD. d) Agree 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. e) Agree the modification item(s) will not be removed from the worksite without the program’s prior written approval, as long as the worker is employed by the employer in work for which the modification is necessary. f) Complete the attached job analysis, unless the program determines it is not necessary. PROGRAM USE ONLY Worksite modification item(s) Cost* Worker Property of: Employer Other 1. 2. 3. 4. 5. 6. 7. Total cost: $0.00 * Three competitive quotes are required for chairs costing more than $1,000. Items costing more than $2,500 require a different contract. This agreement is not valid until signed by an authorized representative of WCD. By our signatures, we agree this job as modified is appropriate employment. We understand WCD will not directly purchase or otherwise assume responsibility for modification items. We understand WCD 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. Worker signature Date Employer signature Date Send to: Preferred Worker Program, 350 Winter St. NE, P.O. Box 14480, Salem, OR 97309-0405 WCD USE ONLY Maximum approved under this agreement Effective date: Data entry $ End date: Certified true, accurate, correct, and an appropriate expenditure for this program. Program approval Date WCD Reg. No. 440-1930 (7/05/DCBS/WCD/WEB) American LegalNet, Inc. www.USCourtForms.com American LegalNet, Inc. www.USCourtForms.com