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Fillable Printable Form 207-171-000

Fillable Printable Form 207-171-000

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 CodeOutcome Code Narrative:
Detail of Outcome
Attached Documents
Payee ID/BranchProvider IDVRC Name/Signature
Job Analysis - Job of InjuryLabor Market Information
Job Analysis - Other RTW optionsVocational Eval/Testing results
Educational HistoryPre-Job/Job Mod Consultation Eval
Work HistoryPhysical Capaciaties/Relevant Med Info
Other (please list below)Job Offer Letter
RESET
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