Submit to: Department of Consumer and Business Services Workers' Compensation Division 350 Winter St. NE P.O. Box 14480 Salem, Oregon 97309-0405 Worker name: Insurer: WCD file no.: Claim no.: Vocational Closure Report DOI: 1. End of eligibility for vocational services a. Reason (check up to two): Reason Rule(s) that apply OAR 436-120Code EM JE FC FC FC FC FC FC FC FC Reason Rule(s) that apply OAR 436-1200165(7) 0165(10) 0165(15) 0165(16) 0165(1) Code DS NF DA MS UW SH RR CW OT Suitably employed more than 60 days 0165(2) Refused offer of or left suitable job 0165(3), (4), and (6) Failure to cooperate or misbehavior involving one of the following: Participating in light-duty work 0165(5) Refused suitable training site 0165(8) Develop or participate in RTW plan 0165(9) Fails to notify counselor 0165(9) Misrepresented relevant information 0165(11) Returning property provided by insurer 0165(12) Misused funds 0165(13) Harassment, other abuse 0165(14) Declined or unavailable for services Voc assistance won't resolve unemployment Claim Disposition Agreement Maximum services New information: Not authorized to work in the U.S. No longer has substantial handicap Released to regular work Can return to other suitable and available work Other (describe below): b. Decision effective date: c. Return to work. Complete if code checked above includes EM or JE: RTW date: RTW weekly* wage: Employer is: Job type is: $ SOC/DOT code: Job title: employer at aggravation modified new employer new employer at injury regular * To convert an hourly wage to weekly, multiply hourly wage by hours worked per week. To convert a monthly wage to weekly, divide monthly wage by 4.35. 2. End of training a. Did worker complete training? b. Date training ended: c. Date Notice of End of Training sent to worker: Yes No 3. Return-to-work and rehabilitation providers and costs List providers below. Enter total costs of vocational assistance since the most recent start or restoration of assistance. Do not include costs for eligibility evaluations or temporary disability during training. a. Direct worker purchases under OAR 436-120-0710 (tuition, fees, books, OJT reimbursement, mileage, etc.): $ b. RTW and vocational assistance providers (List in chronological order, with most recent provider last). Organization names: Professional costs: $ $ $ Signature Insurer/provider: Date: 440-2800 (6/12/DCBS/WCD/WEB) WCD use only Phone: 2800 American LegalNet, Inc. www.FormsWorkFlow.com