Form RW01 at a glance
What it is: RW01 is the Report of Work Ability of the MN Department of Labor and Industry Workers' Compensation Division.
Where and when to file: Mail to: MN Department of Labor and Industry Workers' Compensation Division PO Box 64221 St. Paul, MN 55164-0221. The health care provider must provide the Report of Work Ability to the employee and place a copy in the medical record. Each health care provider directing the course of treatment must complete a Report of Work Ability within 10 days of a request for a Report of Work Ability from the insurer, or at the applicable interval.
A filled-in Form RW01 example: a provider reports work with restrictions
How to fill out Form RW01, box by box
Employee, Employer, Insurer and Insurer claim number
Print in ink or type. Enter dates in MM/DD/YYYY format.
Identify the employee by name, WID or social security number, and date of injury.
Identify the employer at the time of the employee's claimed work injury.
If known, identify the workers' compensation insurer at the time of the claimed injury, or the workers' compensation third-party administrator. Also indicate this workers' compensation payer's claim number.
Date of most recent examination by this office
Indicate the date of the most recent examination by the office. The Report of Work Ability should be completed based on this evaluation.
Employee is able to work or unable to work
Identify the appropriate option which best describes the employee's current ability to work by checking box 1, 2, or 3.
If the employee is able to work without restrictions, fill in the beginning date.
If the employee is able to work with restrictions, fill in the date any restriction of work activity is to begin and the anticipated ending or review date.
Describe any restrictions in functional terms (e.g., employee can lift up to 20 pounds, 15 times per hour; should have 10 minute break every hour).
If the employee is unable to work at all, fill in the date the restriction of work activity is to begin and the anticipated ending or review date.
The next scheduled visit is
Indicate the date of the next scheduled visit or indicate that additional visits will be scheduled as needed.
Name, Signature, Degree, Address and Phone
Identify the health care provider completing the report by name, professional degree, license or registration number, address and phone number.
Include the signature of the health care provider and date of the report.
More rules for Form RW01
Any person who, with intent to defraud, receives workers' compensation benefits to which the person is not entitled by knowingly misrepresenting, misstating, or failing to disclose any material fact is guilty of theft and shall be sentenced pursuant to section 609.52, subdivision 3.
The Report of Work Ability must either be on this form or in a report that contains the same information.
If you have questions, please call the claim representative or the Department of Labor and Industry, Workers' Compensation Division at (651) 284-5032 or 1-800-342-5354.
If your situation is different
Each health care provider directing the course of treatment must complete a Report of Work Ability within 10 days of a request, or at the applicable interval
Each health care provider directing the course of treatment for an employee who alleges to have incurred an injury on the job must complete a Report of Work Ability within 10 days of a request for a Report of Work Ability from the insurer, or at the applicable interval (Minn. Rules 5221.0410, subp. 6): 1. every visit if visits are less frequent than one every two weeks; 2. every 2 weeks if visits are more frequent than once every two weeks, unless work restrictions change sooner; and 3. upon expiration of the ending or review date of the restrictions specified in a previous Report of Work Ability.
Common questions about Form RW01
Where do I file it?
Mail to: MN Department of Labor and Industry Workers' Compensation Division PO Box 64221 St. Paul, MN 55164-0221. This form must be provided to the employee. The employee must promptly provide a copy of this report to the employer or workers' compensation insurer, and qualified rehabilitation consultant if the employee has one.
Sources
[1] Form RW01 (5/17), Report of Work Ability, MN Department of Labor and Industry (the Official source link on this page).