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. Employ....
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How to fill out the Scodrdot Form online
Filling out the Scodrdot Form is an essential step in assisting the assigned rehabilitation specialist in completing the eligibility evaluation report. This guide provides you with clear and detailed instructions on how to accurately complete the form online.
Follow the steps to fill out the Scodrdot Form online effectively.
- Click ‘Get Form’ button to obtain the Scodrdot Form and open it in your preferred online form editor.
- Begin with section 1 by entering the Employee's name in the format: Last, First, Middle Initial.
- In section 2, input the Date of injury using the format MM/DD/YYYY.
- Complete section 3 by filling in the employee's address, including city, state, and zip code.
- In section 4, enter the Social Security Number of the employee.
- Provide the telephone number in section 5.
- Fill out the Date of Birth in section 6 using MM/DD/YYYY format.
- Indicate the Employer's name in section 7.
- In section 8, enter the Insurer or adjusting company's name.
- Complete section 9 with the address of the insurer/adjusting company, including city, state, zip code, and telephone.
- In the optional sections, attach or reference any necessary documentation, such as job descriptions, employer comments, and rehabilitation information.
- Fill in the information needed for the administrator's annual report in sections 21-24, including eligibility evaluation costs and certification of service.
- Finally, save your changes, and choose to download, print, or share the completed Scodrdot Form as needed.
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