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Selection of appropriate job descriptions from U.S. DOL 1991 Revised DOT and 1993 SCODRDOT and submission to physician for review. Physician s review and comments on appropriate SCODRDOT job descriptions. 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. 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 THE FOLLOWING MAY BE ATTACHED OR COVERED IN THE EVALUATION REPORT Employee s description of job at the time of injury. Employer s offer of alternative employment if alternative employment has been offered. 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. physical demands. 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. THE FOLLOWING INFORMATION IS NEEDED FOR THE ADMINISTRATOR S ANNUAL REPORT PER AS 23. 30. 041 b Eligibility evaluation cost billed to Employer at the following rate per hour Please attached a copy of your billing statement. 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. 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. 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.

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