Request For Administrative Approval
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Request For Administrative Approval Form. This is a Oregon form and can be use in Vocational Rehabilitation Workers Comp.
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Tags: Request For Administrative Approval, 1084, Oregon Workers Comp, Vocational Rehabilitation
Submit to:
Department of Consumer & Business Services
Workers’ Compensation Division
350 Winter St. NE
P.O. Box 14480
Salem, Oregon 97309-0405
Request for
Administrative Approval
Date:
Worker:
Counselor name:
WCD file no.:
Phone:
Vocational rehabilitation organization (name, city):
Insurer:
Claim no.:
DOI:
Reason for request (check one):
Extension of training beyond 16 months; director’s approval required by ORS 656.340(12)
Other (explain):
Approval requested for:
1. Extension of training beyond 16 months due to:
a)
b)
Exceptional disability
Exceptional loss of earning capacity
Explain what you are requesting and why it is necessary.
Attach all medical and vocational reports or other
information that supports this request that you have not
already submitted to WCD.
2. Director’s Waiver (OAR 436-120-0003(5))
3. Other:
INSURER APPROVAL:
Insurer signature
Date
Phone:
WCD APPROVAL:
WCD signature
Date
For WCD use only
440-1084 (12/07/DCBS/WCD/WEB)
1084
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