Department of Labor & Industries Crime Victim Compensation Program PO Box 44520 Olympia WA 98504-4520 MEDICAL CERTIFICATION OF TIME LOSS Victim's name Date of crime Claim number State Current mailing address Last date worked / Date returned to work / / / ZIP Was sick leave or disability insurance paid? If yes, for what period? Yes Check if address is new No If not working, state why Have you applied for or are you receiving benefits from: Social Security Employment Security Date Public Assistance Claimant's signature / / Most recent treatment date Provider's Statement (all questions must be answered) / / Is treatment concluded and the condition stable? Yes No Has patient been released for work? Yes No Will permanent impairment result from this injury? Yes No Maybe Date released / / Any physical and/or mental health restrictions? If not released, when do you anticipate release for work? / / Remarks: Date Print attending provider's name and title Attending provider signature TO CLAIMANT: Upon completion and return of this form, determination and payment of compensation for wage loss will be made, if indicated. NOTE: Persons making false statements in obtaining Crime Victim benefits are subject to civil or criminal penalties under the law. F800-012-000 medical cert ification of time loss F800-012-000 medical cert ification of time loss 3-00 3-00 American LegalNet, Inc. www.USCourtForms.com