Return To Work Toolkit
An Employer’s Guide to Return to Work
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Return To Work Toolkit
An Employer’s Guide to Return to Work
This return-to-work toolkit is a collection of best practices,
forms and resources that explain the steps for improving the
way a workplace injury and return-to-work opportunities are
managed in your business. This guide can — and should — be
implemented in any workplace.
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Table of Contents
Return-to-work toolkit ..................................................................................... 4
How to use this toolkit ...................................................................................................................... 4
Importance of return to work............................................................................................................. 4
How you benefit ............................................................................................................................ 5
How your employee benefits ........................................................................................................ 5
Creating a return-to-work culture ...................................................................................................... 6
What to do before an injury .............................................................................................................. 7
What to do after an injury ................................................................................................................. 8
Job modifications and pre-job accommodations ............................................................................... 9
What is a job modification? ........................................................................................................... 9
What is a pre-job accommodation? .............................................................................................. 9
When does L&I offer financial assistance with job modifications? ................................................. 9
What is the process for requesting the L&I benefit? ...................................................................... 9
How can I get more information about L&I’s job modification benefit? .......................................... 9
How L&I can help you—employer incentives .................................................................................. 10
Washington Stay at Work ........................................................................................................... 10
Incentives ................................................................................................................................... 10
Application process .................................................................................................................... 10
Wage reimbursements ............................................................................................................... 10
Expense reimbursements ........................................................................................................... 11
Preferred Worker Program ............................................................................................................. 11
Employer incentives ................................................................................................................... 11
Claim-Free Discount ...................................................................................................................... 11
L&
I staff resources ......................................................................................................................... 12
Claim Manager ........................................................................................................................... 12
Vocational Recovery Services .................................................................................................... 12
Early Return-to-Work Team ........................................................................................................ 12
Division of Occupational Health and Safety (DOSH) ...................................................................... 13
Risk management ...................................................................................................................... 13
DOSH consultation ..................................................................................................................... 13
Contact information ........................................................................................................................ 13
Guidance on Templates ................................................................................................................. 14
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Grab and Go Packets for injured employees .................................................................................. 15
Return to Work Policy Statement ................................................................................................... 15
Provide a return-to-work policy statement to all employees. ....................................................... 15
Roles and Responsibilities ............................................................................................................. 15
Employee responsibilities: .......................................................................................................... 15
Owner/manager/supervisor responsibilities: ............................................................................... 16
Return-to-work coordinator responsibilities: ................................................................................ 16
Employee Incident Report Form ..................................................................................................... 17
First five steps to your return to work .............................................................................................. 18
Injured on the job? Return-to-work checklist for supervisors .......................................................... 19
Incident Investigation Report ...................................................................................................... 20
Sample letter to attending provider ................................................................................................. 24
Sample Formal Job Offer Letter Option 1 – Permanent Job Offer .................................................. 25
Sample Formal Job Offer Letter Option 2 – Light Duty Job offer .................................................... 26
Please contact the claim manager to discuss all job offer requirements ..................................... 26
Claim contacts ............................................................................................................................... 27
Incorporate this template in your return-to-work toolkit
for both employees and supervisors. .......................................................................................... 27
Notice to Employees ...................................................................................................................... 28
Return-to-Work Incentive Programs ........................................................................................... 28
Stay at Work Program ................................................................................................................ 28
Preferred Worker Program ......................................................................................................... 28
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Return-to-work toolkit
Calamity strikes. One of your employees is injured on the job and faces a lengthy
recovery. You are concerned about your employee and your business — not to
mention the cost of your workers’ compensation insurance. By getting your
employee back to work as soon as medically possible, you can help your
employee, your business and your bottom line.
This booklet explains the importance of “return to work” in assuring the best
possible recovery for your employee with the least impact on your business.
HOW TO USE THIS TOOLKIT
This return-to-work toolkit is a collection of best practices, forms and
resources that explain the steps for improving the way a workplace injury
and return-to-work opportunities are managed in your business. This guide
can — and should — be implemented in any workplace.
Helping injured employees return to work as soon as medically possible is a
priority for the Department of Labor & Industries.
Return to work can speed an employee’s recovery and prevent long-term
workplace disability while reducing the financial impact of a workers’
compensation claim.
IMPORTANCE OF RETURN TO WORK
Numerous occupational health studies have identified a connection between the duration of a workers’
compensation claim and long-term loss of earning power. The longer an employee remains off work, the harder it
is for them to return to their original job and income. A solid return-to-work program at your company helps an
injured employee get back to work quickly and safely.
While preventing workplace injuries is the best way to keep employees safe and costs down, an effective
workplace return-to-work program is your best way to manage costs and improve recovery after an injury has
occurred.
Employers can help their workers avoid permanent work disability by providing opportunities for their workers to
be productive while recovering at work.
Case study of early
return to work
“The longer an employee
remains off work the harder
it is for them to return to
their original job and
income.”
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How you benefit
Providing a quick return to work for employees injured on the job reduces
the financial impact on your workers’ compensation premiums and helps
their long-term recovery. In addition to reducing claim costs and insurance
premiums, an effective return-to-work strategy:
Retains an experienced employee.
Keeps productivity levels up.
Reduces the cost of hiring and training new employees.
Preserves better employee relations.
Creates an opportunity to complete work usually left undone.
May reduce the risk of re-injury.
Provides opportunity for potential wage, training and equipment
reimbursements through the L&I Stay at Work Program.
How your employee benefits
Return to work is key to helping your employee recover quickly. By having
an effective return-to-work strategy for your employee and bringing them
back to work as soon as medically appropriate after a workplace injury, the
employee will benefit by:
Preserving long-term earning power.
Keeping them engaged in the recovery process by being active.
Maintaining positive work relationships.
Shifting focus from “dis-ability” to ability.
Reducing the risk of re-injury.
Providing job and financial security.
Acknowledging that you value them and their contribution to the company.
The most important benefit to you and your employee is the communication and connection that return to
work provides.
Benefits of return
to work
Employer:
Reduced labor cost
Increased productivity
Improved employer image and
brand
Retain a valuable employee
Reduced hiring and training
costs
Increased morale
Worker:
Maintain regular wage
Keep workplace relationships
Increase long-term earning
capacity
Improved quality of life
Preserve self-esteem
Avoid permanent disability
Retain skills
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CREATING A RETURN-TO-WORK CULTURE
A successful return-to-work program begins with you, the business owner and top management. You must believe
in the benefits of a return-to-work culture, and establish a streamlined process where everyone knows their roles
and responsibilities. Set an aspiration goal for 100% of your employees to know you have light duty available for
them if they are injured on the job.
As you set the direction and vision for your company, your employees hold the prevailing narrative about the
return-to-work culture. Remember, an injury is not when you develop the culture. Engage your employees early
and often in the development and discussion of return-to-work. Build their awareness of your expectations
through conversation, policy, and appropriate documentation for your industry. Include your employees in the
development of light duty opportunities to create a collaborative environment where everyone is engaged in your
return-to-work culture.
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WHAT TO DO BEFORE AN INJURY
Establish a strong safety program. All workplace injuries are
preventable. Use the resources in this toolkit to get yours started.
Establish written return-to-work policies (see Sample Return-to-
work Policy Statement).
- This information should be part of your new employee orientation, so
all employees know what to do when an accident occurs.
- Make sure everyone knows and understands their roles and
responsibilities.
Designate a return-to-work lead.
- Report all injuries to your return-to-work lead.
- The return-to-work lead should have the authority to facilitate
return to work.
Document physical descriptions for all of your company’s jobs.
- Use the fillable Employer’s Job Description Form to document a
physical description for each job category.
- Check the box “Job of Injury” on the form to designate these
descriptions as the job the worker was doing before an injury
occurred.
Identify light-duty jobs before an injury occurs. Use the fillable
Employer’s Job Description Form to document physical descriptions
for each job category.
- Check the box “light-duty/transitional” on the form to designate the
description as the job the worker can do after the injury occurs.
- Create a light-duty job description that anyone in the company
could perform after an injury. Possible examples include
answering phones or receptionist duty.
Include employees in the identification and design of the light- duty work option.
Create Grab and Go Packets for injured employees.
- Create Grab and Go Packets to be given to the employee after a workplace injury. They will take it with
them to their attending provider. (Templates in the appendix)
- The packet should include:
» A cover letter to the attending provider that expresses your company’s commitment to return to work.
» Employee Incident Report Form
» Employee handout: First five steps to your return to work.
» The job description for the job of injury.
» The job description for the transitional/light-duty job.
» Job offer letter
What is light duty?
Light duty is work you may offer
your employee for them to perform
while they recover, within their
medical restrictions.
Light duty does not have to be
directly related to the work they
were performing at the time of
injury. It could mean:
Working shorter hours.
Completing some original
duties part-time and gradually
increasing to full-time work.
Performing different duties with
lighter physical demands and
growing into their original
duties.
Providing tools, equipment or
appliances to help the employee
complete their job.
Creating a new job with for the
employee within their
restrictions while they recover.
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WHAT TO DO AFTER AN INJURY
As soon as a workplace injury occurs, you should follow your established
return-to-work process.
Have your employee seek medical attention immediately. For death or in-
patient hospitalization, call 1-800-423-7233 within eight hours.
Submit the employer portion of the Report of Accident through our
online FileFast system.
- You can monitor the entire claim file on the Claim and Account
Center.
Contact your employee and stay in contact.
- Let them know that you care and you want them to return to work
as soon as possible. Knowing they are missed by their teammates
will help speed their recovery.
Give your employee a Grab and Go packet to take to their
attending provider appointment.
Ask your employee for the list of restricted activities they can’t
perform during recovery. Their attending provider would have
given this to the employee at their appointment.
- Providers can bill L&I for consultation about return to work, so you may contact the provider to:
» Review the job of injury as well as any other light-duty position available to your employee.
» Clarify any of the medical restrictions.
- If you need help communicating with the attending provider, contact the assigned L&I claim manager.
Prepare a light-duty job offer for your employee. Make sure that it matches the written restrictions. Best
practice – Engage employee when identifying light-duty work. Let them know you are confident that they
can heal and recover while working.
Formally offer the light-duty job to the employee.
- Even though the employee took the Grab and Go Packet to the attending provider and the attending
provider signed off on the job description, the best practice is to offer the job to the worker in writing.
- Contact the claim manager to discuss all job offer requirements.
- Document the date you send the letter, and include the following elements:
» Job title
» Supervisor and contact information
» Work Schedule
» Salary and health care benefits
» Location
» Start date and time
Conduct an incident investigation.
- Determine root causes and identify solutions to prevent similar incidents, and then document the
investigation using the Incident Investigation Report.
Ideas for creating
a light-duty job
description
Include employees and unions in
the process and ask for their
suggestions.
Consider adapting existing jobs or
reorganizing current job tasks.
Visit the Job Accommodation
Network for ideas on how to
modify your current job positions
into light- duty job descriptions.
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JOB MODIFICATIONS AND PRE-JOB ACCOMMODATIONS
What is a job modification?
A job modification is an adjustment or alteration to the way a job is performed. The modification may be
temporary or permanent. Some workers may be eligible for an L&I benefit assisting with a job modification.
What is a pre-job accommodation?
This is an accommodation that may allow a worker to participate in a
retraining plan to be employable.
When does L&I offer financial assistance with job
modifications?
For eligible workers, L&I will provide financial assistance with job
modifications. L&I may pay for a consultation and special equipment or
tools so that the worker can return to their job of injury, or a new job. To be
eligible for the L&I benefit a worker must:
Have an open and allowed claim (self-insurance employers are eligible
for reimbursements after the fact).
Be off work or have been taken off work in the past.
Be placed on restrictions by the attending provider that prevent them from doing their regular job due to the
effects of the industrial injury or occupational condition.
What is the process for requesting the L&I benefit?
Contact the claim manager to request a consultation on the job modification.
You must identify any existing work restrictions at the time of the request.
A number of involved parties may request a job modification consultation:
attending provider, consulting provider, vocational services provider, claim
manager, third party administrator, and worker.
Either the employer or the worker may own the equipment or tools L&I
purchases as part of a job modification. Both parties must sign an agreement
specifying ownership. Typically, the employer will own the non-portable
items and items bolted to the work site.
How can I get more information about L&I’s job
modification benefit?
Visit L&I’s Job Modification website:www.Lni.wa.gov/JobModification
Call the assigned claim manager.
Call the L&I office nearest you.
Example of a job
modification:
A worker developed carpal tunnel
syndrome due to gripping small
pliers during mechanical work.
Restrictions included reducing the
amount of force use to grasp tools.
Modification: Worker was equipped
with pliers designed with larger and
longer handles to reduce grip force.
Example of a pre-job
accommodation:
A worker was participating in a
retraining plan as a computer
operator at a local college.
Restriction: Due to a shoulder
injury, they could not carry required
books to class.
Accommodation: Rolling book bag.
Using job modification funding to
purchase the bag, the worker no
longer had to carry their books and
was able to complete their training.
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HOW L&I CAN HELP YOU—EMPLOYER INCENTIVES
In order to help you establish a return-to-work culture at your business, we offer many services that can benefit
your injured employee and your company’s financial health. There are no fees for these services.
Washington Stay at Work
Stay at Work is a financial incentive that helps employers keep injured workers
on the job by bringing them quickly and safely back to light-duty or transitional
work. L&I reimburses eligible employers for a portion of this cost.
Incentives
Eligible employers may receive:
50% of the worker’s base wages for the light-duty or transitional work:
- For up to 66 days in which work was actually performed per claim
(fewer than eight hours still counts for one day).
- Within a 24-month period.
- Up to $10,000 per claim.
Expense reimbursements for tools and training necessary to do the
light-duty or transitional work:
- Training fees or materials, up to $1,000 per claim. (Examples: tuition, books or supplies)
- Tools up to $2,500 per claim. (Examples: special wrench or keyboard tray)
- Clothing up to $400 per claim. (Example: steel-toed boots)
Application process
Please visit www.Lni.wa.gov/StayatWork to learn more about eligibility and to apply.
Wage reimbursements
For wage reimbursements, L&I will need:
A completed Wage Reimbursement form (www.Lni.wa.gov/StayatWork).
Payroll information:
- Payroll records and daily timesheets
A description of physical restrictions from the attending provider.
- If the information is in the claim file, you don’t need to send it in.
- You can view the claim file at www.Lni.wa.gov/secure.
Light-duty or transitional job description that is complete and provider-approved.
- It must include the tasks and physical requirements of the job.
- You must provide a copy of the job description to the worker when sending to attending provider for review.
Control your
workers’
compensation rates
Time-loss duration is the biggest
driver of your worker’s
compensation rates.
By bringing a worker back to work
as soon as medically possible, you
can shorten or eliminate the period
that time-loss benefits are paid.
This could reduce the claim cost
used to calculate your rates.
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Expense reimbursements
For expense reimbursements, L&I will need:
A completed Expense reimbursement form (www.Lni.wa.gov/StayatWork).
Itemized receipts for the goods and services you purchased.
- Must include purchase date.
- Must be purchased on or after the date you made the light duty job offer.
A description of physical restrictions from the attending provider.
A light-duty or transitional job description that is complete and provider-approved.
PREFERRED WORKER PROGRAM
When a worker is unable to return to their job of injury due to permanent medical restrictions, L&I may certify
them as a preferred worker. Employers who hire a preferred worker for a medically approved permanent position,
or retain an eligible employee in a permanent light-duty position, may qualify for financial incentives.
Employer incentives
Eligible employers may receive:
Financial protection against subsequent claims while the employee is a preferred worker.
Premium relief on a portion of your premiums.
50% of the worker’s base wages for the approved preferred worker job for 66 days worked, up to $10,000.
Expense reimbursements for tools and training necessary to do the preferred worker job:
- Tools up to $2,500 per claim.
- Clothing up to $400 per claim.
Payment for continuous 12 months employment, up to $10,000 per claim.
To learn more about the Preferred Worker Program and eligibility go to www.Lni.wa.gov/PreferredWorker.
CLAIM-FREE DISCOUNT
If you prevent workplace injuries, you can qualify for a Claim-Free Discount (www.Lni.wa.gov/insurance/rates-
risk-classes/rates-for-workers-compensation/claim-free-discount). Employers qualify for a Claim-Free
Discount after three years without a “compensable” claim (a claim involving time-loss or permanent disability
award).
The discount saves employers between 10-40% from the base insurance rate for their risk class, depending on the
company size.
A single compensable claim will eliminate the Claim-Free Discount. Losing the discount may be more costly than
preventing injuries, compensation duration, or implementing your return-to-work plan.
For more information, contact your account manager at 360-902-4817.
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L&I STAFF RESOURCES
Claim Manager
L&I claim managers are instrumental in preventing work disability by facilitating a quick and successful return-
to-work. They monitor the claim for appropriate medical and vocational needs, and review and consider
authorizations for medical treatment and equipment.
The claim manager will communicate with the business to review all return-to-work options. If needed, a
vocational referral is created to assist all parties. The acting vocational rehabilitation counselor will engage the
worker regarding return to work and submit progress and closing reports. The claim manager will monitor the
vocational progress and close vocational services when appropriate.
Working with the private vocational rehabilitation counselor to aid in vocational recovery and prevent work
disability is essential to successful claim management.
Vocational Recovery Services
Vocational recovery services are generally the first referral made for vocational services on a claim. This service
represents an evidence-informed, worker-centric work disability prevention model for returning workers to work.
During vocational recovery services, the vocational rehabilitation counselor (VRC) will engage with the worker,
employer, and medical providers to prevent unnecessary delays, prevent a confusing process, prevent unnecessary
duration, and prevent unrealistic return to work expectations.
Based on the worker’s goals, the VRC will explore options of returning to work with the worker, and will work with
the worker, medical provider, employer, and local WorkSource locations.
Contact the assigned claim manager for vocational recovery assistance when returning an employee back to work.
Early Return-to-Work Team
The Early Return-to-Work (ERTW) team provides return-to-work planning assistance to employers. ERTW
vocational services specialists (VSS) work with the employer to remove barriers to maintain employment by
offering education, support, and tools. Services provided:
Identify specific job tasks for light-duty work.
Assist in designing return-to-work programs for current and future use.
Create job analyses and/or light duty job descriptions.
Provide ergonomic and job modification consultations.
Educate employers on light duty and Stay-at-Work programs.
To contact the ERTW team, call your local L&I office or send an email directly to the team at
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DIVISION OF OCCUPATIONAL HEALTH AND SAFETY (DOSH)
Risk management
A risk management consultant can meet with you to help you review your workers’ compensation premiums and
explain how your premiums are calculated. They can assess your current business operations to identify injury
trends and costs unique to your account, and identify useful safety and return-to-work strategies to help you
mitigate or minimize potential rate increases to protect your future rates.
DOSH consultation
The best injury is one that doesn’t happen. L&I’s Division of Occupational Safety and Health (DOSH) provides
free on-site consultations to help employers create safe and healthy workplaces. They also provide free training,
safety and health programs and other resources to help prevent, find and fix hazards.
To contact or schedule a consultation with a risk manager or DOSH consultant email
DOSHConsultation@Lni.wa.gov or call your local L&I office or 1-800-423-7233.
CONTACT INFORMATION
L&I is here to help you create your return-to-work culture. Don’t hesitate to reach out if you have questions or
need assistance.
Claim-Free Discount
www.Lni.wa.gov/ClaimsFreeDiscount
Account manager: 360-902-4817
DOSH consultation
www.Lni.wa.gov/safety-health
Call your local office or email
DOSHConsul[email protected]v
DOSH risk management
www.Lni.wa.gov/safety-health
Call your local office or email
DOSHConsul[email protected]v
Early Return to Work
Email [email protected]
FileFast
www.Lni.wa.gov/FileFast
360-902-5470 or 1-877-561-3453
Job Accommodation
Network
www.askjan.org
Job Modification
www.Lni.wa.gov/JobModification
My L&I – follow your claim
www.secure.Lni.wa.gov/home
Web Customer Support (for
technical issues): 360-902-5999
Stay at work or Preferred
Work Program
www.Lni.wa.gov/EmployerIncentives
Toll free 1-866-406-2482
L&I Office Locations
www.Lni.wa.gov/Offices
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GUIDANCE ON TEMPLATES
All the templates are samples and you are encouraged to implement the policies and return to work culture that
work best for you and your employees.
Return to Work Policy Statement – Use this to start the conversation with your employees about your return-to-
work policy. This will help them know that if they are injured, you have work for them so they can quickly and
safely return to work.
Roles and Responsibilities – This form will help you and your team clearly know who is responsible for what in
the event of an emergency.
Employee Incident Form – Strengthen your safety culture by having this filled out after any near miss or injury
to develop awareness of opportunities to enhance employee safety moving forward. Remember, the best
intervention to an injury is prevention.
First five steps of Return to Work – Recommend this being the kick off to your Grab and Go packet. This will
help act as a reminder to your employee during a time when they may not be thinking about your return-to-work
opportunities.
Return to work checklist for Supervisors – Recommend sending this to supervisors for follow up when an
employee is injured as a reminder of the supervisor role and responsibility.
Supervisor Incident Investigation Report – This is the supervisor’s opportunity to review the employee’s
incident form and provide additional information or safety recommendations. This information can complement
your safety team’s work in prevention strategies.
Employer Job Description – It is recommended you have two or three light-duty job descriptions included in
your Grab and Go packets that your employee can take with them to the provider when injured to discuss light-
duty options available for the employee to start right away.
Sample Letter to the Attending Provider – Use when you, as the employer, are working to obtain a medical
release for a light duty or permanent position from the attending provider. Always send a copy of the job
description to your employee when asking the provider about their ability to work.
Sample Light-Duty and Permanent-Duty Job Offer letters - While these are samples, if you choose to create
your own letters, it is highly encouraged to connect with the claim manager to discuss what they need to
determine a job offer as valid. Best practice is to engage the claim manager in this discussion to ensure you
receive the needed information and support for a successful return to work.
Claim Contacts – Use this as a handy reference sheet for whom you’ve worked with during the life of a claim. It
can also come in handy when you need to contact someone with a quick question.
Notice to Employees – Put this up in a visible location as a reminder to all staff that you support a culture of
Return to Work.
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GRAB AND GO PACKETS FOR INJURED EMPLOYEES
Your packets should include:
A cover letter to the attending provider that expresses your company’s commitment to return to work.
Employee Incident Report Form
Employee handout: First five steps to your return to work.
The job description for the job of injury.
The job description for the transitional/light-duty job.
Job offer letter
RETURN TO WORK POLICY STATEMENT
Provide a return-to-work policy statement to all employees.
[Company name] is committed to providing a safe and healthy workplace for its employees and the prevention of
workplace injury and illness is a primary objective.
In the event an employee is injured on the job, [Company name] has implemented a return-to-work process. This
process will provide injured or ill employees with the opportunity to return to safe, productive work as soon as
medically possible.
The ultimate goal is to return the employee to their original job. If the employee is unable to perform the tasks of
the original job, the employer will follow the return-to-work process to attempt to provide light-duty work that
meets with the approval of the attending health care provider.
The support and participation of management and all employees is essential to the success of the return-to-work
process and [Company Name].
ROLES AND RESPONSIBILITIES
The following roles and responsibilities are written from the perspective of the employer, to use in company
policy or guidelines.
Employee responsibilities:
Understand our procedure for reporting injuries.
Know, follow, and support our return-to-work program.
Assist in the creation of possible light-duty work by providing your input to your supervisor.
If you are injured on the job:
- Take the letter and job descriptions provided by your supervisor to your attending provider to help
explain our company’s return-to-work process.
- Tell the attending provider that light duty is available.
- Call your supervisor or Human Resources contact once a week.
- Update them on your work status and let them know how you are doing.
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- Follow medical restrictions at home and at work.
- Inform your supervisor or Human Resources contact immediately if your attending provider releases you
to work, or your restrictions change.
Owner/manager/supervisor responsibilities:
Support our return-to-work program.
Train employees on proper reporting of incidents and injuries, as well as your return-to-work procedures;
make sure they know their responsibilities.
Create light-duty assignments that are meaningful and productive.
- Include your employees and union in the development.
Follow Human Resources protocols and hiring practices.
- An effective return-to-work program begins during the initial interview.
If an employee is injured on the job:
- Provide employee with letter and light-duty job description to take to the first medical appointment.
- Ensure all necessary forms are completed and returned.
- Contact the employee once a week to check on how they are doing:
- Ask about any changes in work status.
» Express concern and empathy for your employee’s health and recovery.
» Provide information to our return-to-work coordinator.
» Post “Notice to Employee” to build awareness of return-to-work polices.
Return-to-work coordinator responsibilities:
Support our return-to-work program.
Individualize planning and adapt coordination to the injured worker’s needs.
Maintain ongoing communication with all parties involved.
Manage expectations and ensure all parties understand their responsibilities.
Hold all parties accountable for adhering to the company’s return-to-work program.
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EMPLOYEE INCIDENT REPORT FORM
Your employees may use this form to report all work related-injuries, illnesses or “near miss” events (which could
have caused an injury or illness) – no matter how minor. This helps you to identify and correct hazards before
they cause serious injuries. The employee must complete this form as soon as possible and give it to their
supervisor for further action.
I am reporting a work related:
Injury
Illness
Near miss
Your name:
Job title:
Supervisor:
Have you told your supervisor about this injury/near miss?
Yes
No
Date of injury/near miss:
Time of injury/near miss:
Names of witnesses (if any):
Where, exactly, did it happen?
What were you doing at the time?
Describe step by step what led up to the injury/near miss (continue on the back if necessary):
How could we have prevented this injury/near miss?
What parts of your body were injured? If a near miss, how could you have been hurt?
Did you see an attending provider about this injury/illness?
Yes
No
If yes, whom did you see?
Attending provider ’s phone number:
Date:
Time:
Has this part of your body been injured before?
Yes
No
If yes, when?
Employer:
Your signature (optional):
Date:
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FIRST FIVE STEPS TO YOUR RETURN TO WORK
Give this to an employee who suffers a workplace injury or illness.
We are sorry you have been hurt at work. We want to make sure you know what to do.
1. Report your injury/illness to your supervisor or HR right away.
Discuss: Can you remain at work?
Complete Employee Incident Report form.
Get the attending provider letter, job description of current job and job
description of light-duty job.
☐
2. If you seek medical care
File a claim with L&I.
www.Lni.wa.gov/FileFast.
☐
3. Communicate with your medical provider.
Give your attending provider your claim number if you have already filed
online or by phone.
i. If not, your attending provider can file for you.
Is it safe for you to return to your regular duties?
Is it safe for you to return to work to transitional duties? Let them know
your employer supports this.
Are any activities you should avoid or limit?
If there are restrictions tell the attending provider that your employer
supports your return to work, and give them the attending provider letter
and job descriptions.
☐
4. Call or see your local/designated Human Resources (HR) contact.
Provide a copy of the Activity Prescription Form to your supervisor or
Human Resources contact.
Talk to your supervisor or Human Resources contact about:
i. Why it is important for you to return to work?
ii. What did your attending provider say about returning to
work?
iii. What is transitional duty?
Report any changes in work status.
☐
5. Follow all of your attending provider’s restrictions at home and at work.
☐
Page 19
INJURED ON THE JOB? RETURN-TO-WORK CHECKLIST FOR
SUPERVISORS
Give this checklist to all of your supervisors to use if one of their employees is
injured.
Steps to follow the first day of an injury:
1. Talk to the employee.
Let them know you are here to help. Ask them how they are doing.
☐
2. Provide the worker with a letter for the attending provider that states our company’s
intention to assist our employees in returning to work.
☐
3. Provide the worker with the job description of the job of injury and any pre-identified
light-duty job descriptions to give to their attending provider.
☐
4. At the time of the first medical treatment, get the claim number from the employee — it
will be on the Report of Accident form.
☐
5. Immediately complete the Employers Report of accident form electronically at
www.Lni.wa.gov/FileFast.
☐
6. Establish an individual claim file to keep copies for all paperwork relating to the claim.
☐
7. Check in with the employee once a week.
Let them know you miss them and you are eager to have them back when it is
medically appropriate.
Ask them how they are doing.
Did the medical provider say it is safe for them to return to work at regular
duties?
Did the medical provider say it is safe for them to return to a light-duty job?
i. Confirm that they know what activities to avoid or limit.
☐
8. Investigate the industrial accident within 24 hours of the incident to identify potential
hazards and revise safety procedures, if necessary.
☐
9. Report a death or in-patient hospitalizations within eight hours, report a non-
hospitalized amputation or loss of eye within 24 hours.
• To report call 1-800-423-7233 or visit an L&I office and ask to speak with a DOSH
employee.
☐
Page 20
Incident Investigation Report
Instruction: Complete this form as soon as possible after an incident that results in serious injury or illness
(optional: use to investigate a minor injury or near miss that could have resulted in a serious injury or illness).
This is a report of a: Death Lost Time Dr. Visit Only First Aid Only Near Miss
Date of incident: This report is made by: Employee Supervisor Team Final Report
Step 1: Injured employee (complete this part for each injured employee)
Name:
Sex: Male Female
Age:
Department:
Job title at time of incident:
Part of body affected (shade all that apply):
Nature of injury (most serious
one):
Abrasion, scrapes
Amputation
Broken bone
Bruise
Burn (heat)
Burn (chemical)
Concussion (to the head)
Crushing Injury
This employee works:
Regular full time
Regular part time
Seasonal
Temporary
Months with
this
employer:
Months
doing this
job:
Cut, laceration, puncture
Hernia
Illness
Sprain, strain
Damage to a body system:
Other _
Step 2: Describe the incident
Exact location of the incident:
Exact time:
What part of employee’s workday? Entering or leaving work Doing normal work activities
During meal period During break Working overtime Other
Names of witnesses (if any):
Number of
attachments:
Written witness statements:
Photographs:
Maps / drawings:
What personal protective equipment was the employee using (if any)?
Describe, step-by-step, the events that led up to the injury. Include names of any machines, parts, objects,
tools, materials and other important details.
Page 21
Step 4: How can future Incidents be prevented?
What changes do you suggest to prevent this incident/near miss from happening
again?
Stop this activity Guard the hazard Train the employee(s) Train the supervisor(s)
Redesign task steps Redesign work station Write a new policy/rule Enforce existing policy
Routinely inspect for the hazard Personal Protective Equipment Other:
What should be (or has been) done to carry out the suggestion(s) checked above?
Step 5: Who completed and reviewed this form? (Please Print)
Written by:
Department:
Title:
Date:
Names of investigation team members:
Reviewed by:
Title:
Date:
Step 3: Why did the incident happen?
Unsafe workplace conditions (check all that apply):
Inadequate guard
Unguarded hazard
Safety device is defective
Tool or equipment is defective
Workstation layout is hazardous
Unsafe lighting
Unsafe ventilation
Lack of needed personal protective equipment
Lack of appropriate equipment / tools
Unsafe clothing
No training or insufficient training
Other:
Unsafe acts by people (check all that apply):
Operating without permission
Operating at unsafe speed
Servicing equipment that has power to it
Making a safety device inoperative
Using defective equipment
Using equipment in an unapproved way
Unsafe lifting by hand
Taking an unsafe position or posture
Distraction, teasing, horseplay
Failure to wear personal protective equipment
Failure to use the available equipment / tools
Other:
_
Why did the unsafe conditions exist?
Why did the unsafe acts occur?
Is there a reward (such as “the job can be done more quickly,” or “the product is less likely to be damaged”)
that may have encouraged the unsafe conditions or acts? Yes No
If yes, describe:
Were the unsafe acts or conditions reported prior to the incident? Yes No
Have there been similar incidents or near misses prior to this one? Yes No
Page 22
Department of Labor and Industries
Physician billing codes for Review of Job
Analysis and Job Description:
1038M – Limit one per day
1028M – Each additional review
Employer’s Job Description Form
☐
Job of Injury
☐
Permanent Modified
☐
Light Duty/Transitional
Worker Name:
Claim Number:
Company Name:
Job Title:
Phone Number:
Fax Number:
Hours per day:
Days per Week:
Essential Job Duties:
Machinery, Tools, Equipment, and Personal Protective Equipment:
Frequency Guidelines:
N: Never (not at all)
S: Seldom (1 – 10% of the time)
O: Occasional (11 – 33% of the time)
F: Frequent (34 – 66% of the time)
C: Constant (67 – 100% of the time)
Physical Demands:
Frequency:
Description of Task:
Sitting
Standing
Walking
Heights/Ladders/Stairs
Twisting at the Waist
Bending/Stooping
Squatting/Kneeling
Crawling
Reaching Out
Talking/Hearing/Seeing
L
R
B
Working Above Shoulders ☐ ☐ ☐
Handling/Grasping ☐ ☐ ☐
Fine Finger Manipulation
☐ ☐ ☐
Foot Controls ☐ ☐ ☐
Driving
☐ ☐ ☐
Repetitive Motion ☐ ☐ ☐
Vibratory Tasks
☐
H
☐L ☐ ☐ ☐
Lifting ( ) lbs. ☐ ☐ ☐
Carrying ( ) lbs. ☐ ☐ ☐
Pushing/Pulling ( ) lbs. ☐ ☐ ☐
Comments/Other:
Employer Name (Please Print)
Title
Employer Signature
Date
Page 23
For Healthcare Providers’ Use
Only
Approval
☐
Yes
☐
No
☐
Approved with Modifications
Hours per Day:
Days per Week:
Effective Date:
If no, please list the objective medical finding:
If approved with modifications, describe the modifications needed:
H
ealthcare Provider Printed Name
H
ealthcare Provider’s Signature
Date
Page 24
SAMPLE LETTER TO ATTENDING PROVIDER
Send this letter on company letterhead to the attending provider or send with
employee to their first medical appointment. Attach a copy of their current job
description and the light-duty job description.
RE
: (Worker name)
Claim number ( )
D
ear Dr. Provider (Name),
(
Company name) is committed to assisting our injured employees in returning to work as soon as medically
possible. Attached is a job description for the position of (job title).
This position is for (restricted/light-duty, transitional work, job of injury, modified job of injury, new job or other
option.).
Please review and respond to the job description, outlining any needed modifications. If our employee is not able
to work, please indicate what physical restrictions prevent return to work at this time. This position is currently
available and we are waiting for your approval.
We would appreciate your faxing the job description to us at (company fax number) at your earliest opportunity.
If you have questions or concerns, please call me at (Company phone number). Thank you for your assistance
with our employee’s return to work.
S
incerely,
(
Company claim representative’s name)
(Company name)
cc:
(L&I claim manager’s name - if known)
Department of Labor & Industries
(Employee’s name)
Enclosure: Job Description
Page 25
SAMPLE FORMAL JOB OFFER LETTER OPTION 1 – PERMANENT
JOB OFFER
Please contact the claim manager to discuss all job offer requirements
R
E: Claim number ( )
Dear (name),
We are pleased to offer you work which is expected to continue into the foreseeable future. Your attending
provider released you to perform the work activities outlined in the attached job analysis/description.
Please report for work to (supervisor), on (date and time), at (location address). Your supervisor can be contacted
at (telephone number).
Your work schedule will be (scheduled hours/scheduled days). You will be paid ($00.00) per hour.
({Your health care benefits will resume at the level provided at the time of injury.} or
{We are unable to offer the same health care benefits due to a change in our benefit program.}).
If your job involves fewer hours or reduced wages, you may be eligible for Loss of Earning Power (LEP) benefits.
Contact your L&I claim manager for more information.
If you want to return to work earlier or need more time, please call to discuss. We are happy to work with you.
You are a valued employee, and it is our goal that this job will support your return to work. If you have difficulty
performing the tasks assigned, you must notify your supervisor immediately.
Your signature below acknowledges that you have reviewed this job offer. Declining may affect compensation
benefits.
☐ Yes, I accept this offer.
☐ No, I don’t accept this offer (please comment on backside).
Wo
rker’s signature Date
Page 26
SAMPLE FORMAL JOB OFFER LETTER OPTION 2 – LIGHT DUTY
JOB OFFER
Please contact the claim manager to discuss all job offer requirements
RE
: Claim number ( )
D
ear (name),
We are pleased to offer you temporary work while you recover. Your attending provider released you to perform
the work activities outlined in the attached job analysis/description.
Please report for work to (supervisor), on (date and time), at (location Address). Your supervisor can be contacted
at (telephone number).
Your work schedule will be (Scheduled hours/scheduled days). You will be paid ($00.00) per hour.
{Your health care benefits will resume at the level provided at the time of injury.} Or
{We are unable to offer the same health care benefits due to a change in our benefit program}
If your job involves fewer hours or reduced wages, you may be eligible for Loss of Earning Power (LEP) benefits.
Contact your L&I claim manager for more information.
If you want to return to work earlier or need more time, please call to discuss. We are happy to work with you.
It is our goal that this temporary assignment will aid you in your recovery while you transition back into full work
activities. You are a valued employee, and it is our goal that this job will support your return to work. If you have
difficulty performing the tasks assigned, you must notify your supervisor immediately.
Your signature below acknowledges that you have reviewed this job offer. Declining may affect compensation
benefits.
☐ Yes, I accept this offer.
☐ No, I don’t accept this offer (please comment on backside).
Wo
rker’s signature Date
Page 27
CLAIM CONTACTS
Incorporate this template in your return-to-work toolkit for both employees and
supervisors.
Contact type Name of contact Phone number Email
Work Supervisor
Human Resources
Attending provider
Vocational provider
(if any)
L&I claim manager
Send a secure message
through My L&I
Other
Page 28
NOTICE TO EMPLOYEES
Return-to-Work Incentive Programs
We are committed to return-to-work best practices. We will do everything possible to help our employees return
to work as quickly and safely as possible by providing meaningful and productive temporary and/or permanent
jobs that meet your medical restrictions after a workplace injury. This will help speed your recovery time and
return to your full wages quickly.
We participate in the Department of Labor & Industries financial incentive programs.
Stay at Work Program
The Department of Labor & Industries’ Stay at Work Program helps keep workers on the job by offering financial
incentives that help our company offset the cost of an injury.
Preferred Worker Program
If the injury or illness results in permanent medical restrictions, we may work with you and representatives from
L&I to seek preferred worker certification. This certification allows us to help you transition into a long-term job
that will meet your permanent medical restriction.
For more information, call 866-406-2482.
Upon request, foreign language support and formats for
persons with disabilities are available. Call 1-800-547-8367.
TDD users, call 711. L&I is an equal opportunity employer.
PUBLICATION F243-282-000 [08-2021]
