Form 07 6150 PDF Details

The 07 6150 form serves as a pivotal document within the Alaska Department of Labor & Workforce Development, specifically tailored for the Division of Workers' Compensation, Reemployment Benefits Section, Anchorage, Alaska. This meticulously crafted form functions as a comprehensive Eligibility Evaluation Checklist, designed to facilitate the rehabilitation specialist (RS) in compiling a thorough eligibility evaluation report. Fundamental to the operational workflow, this document encompasses an individual's employment background, including pre and post-injury job descriptions, rehabilitation efforts, and any offers of alternate employment post-injury. It stands as a critical tool in the assessment of a worker's ability to return to the workforce following an injury, encapsulating personal details, employment history, training, and medical evaluations. The form further extends to include documentary evidence required for the Administrator's annual report, emphasizing the economic aspects alongside the eligibility criteria. Specific sections ensure adherence to informational sharing protocols, mandating the distribution of filled forms and accompanying assessments to relevant parties including employees, insurers, and legal representatives hence providing a holistic approach to workplace injury management and reemployment assessment.

QuestionAnswer
Form NameForm 07 6150
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other nameswc6150 scodrdot form

Form Preview Example

ALASKA DEPARTMENT OF LABOR & WORKFORCE DEVELOPMENT Division of Workers' Compensation, Reemployment Benefits Section 3301 Eagle Street, Suite 301, Anchorage AK 99503-4149

ELIGIBILITY EVALUATION CHECKLIST

AWCB Case Number:

INSTRUCTIONS: This form is designed to assist the assigned rehabilitation specialist (RS) in completing the eligibility evaluation report. Information that is included in this form is also used in the Reemployment Benefits Administrator's annual report.

1.

Employee's Name (Last, First, Middle Initial)

 

 

 

2.

Date of Injury

 

 

 

 

 

 

 

3.

Address

 

 

 

 

4. Social Security Number

 

 

 

 

 

 

 

City

State

Zip Code

5.

Telephone

6.

Date of Birth

 

 

 

 

 

 

 

7.

Employer

 

 

8.

Insurer/Adjusting Company

 

 

 

 

 

 

 

9.

Address

 

 

10. Address

 

 

City

State

Zip Code

Telephone

City

State

Zip Code

Telephone

THE FOLLOWING MAY BE ATTACHED OR COVERED IN THE EVALUATION REPORT:

11.

 

 

 

Employee's description of job at the time of injury.

 

 

 

 

 

 

 

 

 

 

 

12.

 

 

 

Employee's description of jobs held and/or for which training was received. (Since ten years prior to injury.)

 

 

 

13.

 

 

 

Employer's description of Employee's job at injury (if different from Employee's).

 

 

 

14.

 

 

 

Employer's offer of alternative employment (if alternative employment has been offered).

 

 

 

15.

 

 

 

Whether Employee has been rehabilitated under a prior workers' compensation claim and returned to work in the same or similar occupation in

 

 

 

 

 

 

 

terms of physical demands.

 

 

 

 

16.

 

 

 

Whether Employee previously declined a plan, received job dislocation benefits and returned to work in the same or similar occupation in terms of

 

 

 

 

 

 

 

physical demands.

 

 

 

 

17.

 

 

 

State of Alaska classified employee has been advised of his/her rights and responsibilities under AS.39.25.158. (This is only applicable if you have

 

 

 

 

 

 

 

been assigned a case in which a State of Alaska employee is the injured worker).

18.

 

 

 

Selection of appropriate job descriptions from U.S. DOL 1991 Revised DOT and 1993 SCODRDOT and submission to physician for review.

 

 

 

19.

 

 

 

Physician's review and comments on appropriate SCODRDOT job descriptions.

 

 

 

20.

 

 

 

Documentation of physician's prediction that a permanent partial impairment rating greater than zero percent is anticipated, or was given, at the time

 

 

 

 

 

 

 

of medical stability.

 

 

 

 

THE FOLLOWING INFORMATION IS NEEDED FOR THE ADMINISTRATOR'S ANNUAL REPORT PER AS 23.30.041(b):

21.

 

 

 

Eligibility evaluation cost billed to Employer $

 

at the following rate per hour $

 

 

(Please attached a copy of your billing statement.)

22.PROOF OF SERVICE: I certify that on the date in #26 below, I mailed a copy of the Eligibility Evaluation Checklist form, eligibility evaluation report, and all attachments, to the following:

 

 

a.

Employee

 

 

 

 

b.

Insurer

 

 

 

 

 

 

 

 

c.

The Reemployment Benefits Administrator at the address in the header

 

 

 

 

 

 

d.

Attorney for Insurer (if represented)

 

 

 

 

 

 

 

 

e.

Attorney for Employee (if represented)

 

 

 

 

 

 

 

 

f.

Other (state name and address below)

 

 

 

 

 

 

 

 

 

NAME:

 

 

 

 

 

 

ADDRESS:

 

 

 

 

 

 

 

 

 

23. Name of Rehabilitation Specialist

24. Signature

 

 

 

 

25. Rehabilitation Specialist's Address

 

 

City

State

Zip Code

Telephone

24. Date Mailed

Form 07-6150 (Rev 12/2012)

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As for the blank fields of this precise PDF, here is what you need to do:

1. The Form 07 6150 usually requires particular details to be inserted. Ensure the subsequent blanks are complete:

Filling in section 1 in Form 07 6150

2. Right after this part is done, go on to type in the suitable details in these - Employees description of job at, THE FOLLOWING INFORMATION IS, Eligibility evaluation cost billed, at the following rate per hour, Please attached a copy of your, a Employee, Insurer The Reemployment Benefits, c d Attorney for Insurer if, and NAME.

Form 07 6150 completion process described (step 2)

A lot of people frequently make mistakes when filling in Employees description of job at in this part. You should read again what you type in right here.

3. This next portion is mostly about ADDRESS, Name of Rehabilitation Specialist, Signature, Rehabilitation Specialists Address, City, State, Zip Code, Telephone, Date Mailed, and Form Rev - type in every one of these blanks.

Filling in segment 3 in Form 07 6150

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