Fillable Printable Form 207-171-000
Fillable Printable Form 207-171-000
Form 207-171-000
SELF INSURANCE
VOCATIONAL SERVICES
CLOSING COVER SHEET
F207-171-000 vocational closing report cover sheet 5-05
Department of Labor and Industries
Self Insurance
PO Box 44892
Olympia WA 98504-4892
Complete this form and place it on top of the closing report.
Referral Type:
Plan Implementation
Worker Name
Claim No.
Date:
Referral Outcome: Write in the outcome code and exact narrative for the outcome you submitted on the
Department of Labor and Industries VOCU screen:
Outcome Code Outcome Code Narrative:
Detail of Outcome
Attached Documents
Payee ID/Branch Provider ID VRC Name/Signature
Job Analysis - Job of Injury Labor Market Information
Job Analysis - Other RTW options Vocational Eval/Testing results
Educational History Pre-Job/Job Mod Consultation Eval
Work History Physical Capaciaties/Relevant Med Info
Other (please list below) Job Offer Letter
RESET
