Retaining Employment and Talent after Injury/Illness Network (RETAIN) Demonstration Projects and Evaluation

OMB Control No.: XXXX-XXXX

Expiration date: XX/XX/XXXX

[STATE NAME] RETAIN Project

Retaining Employment & Talent after Injury/Illness Network

Participant Enrollment Information Form: Part Two
TO BE COMPLETED BY THE HEALTH CARE PROVIDER AND/OR RTW COORDINATOR

*ALL FIELDS REQUIRED*

1. Date of Onset of Primary Injury or Illness:

| | | / | | | / | | | | |

MONTH DAY YEAR

2. Date of Enrollment in RETAIN:

| | | / | | | / | | | | |

MONTH DAY YEAR

3. What is the ICD-10 code of the primary injury or illness?

4. Provide a brief description of the primary injury or illness:

5. Is the primary injury or illness caused, at least in part, by work-related factors?

□ Yes

□ No

6. Is the primary injury or illness part of a workers’ compensation claim?

□ Yes, the worker has filed a claim involving the primary injury or illness

□ No, the worker has not filed a claim involving the primary injury or illness

7. Is the primary condition a result of an accident or injury?

□ Yes, it is the result of an accident or injury

□ No, it is an illness or chronic condition

8. Is the primary injury or illness:

□ New condition

□ Worsening of an existing condition

9. Industry classification of pre-injury/illness employer:

□ Agriculture or Mining

□ Construction or Utilities

□ Manufacturing

□ Retail Trade, Wholesale Trade, or Transportation

□ Information

□ Finance or Real Estate

□ Professional, Management, or Administrative Services

□ Education or Health Care

□ Accommodation and Food Services or Arts and Entertainment

□ Other Services

□ Public Administration

10. Occupational classification of pre-injury/illness job:

□ Management, professional, or related

□ Service

□ Sales and office

□ Natural resources, construction, or maintenance

□ Production, transportation, or material moving

Public reporting burden for this collection of information is estimated to average 5 minutes per respondent. Send comments concerning this burden estimate or any other aspect of this collection of information to the U.S. Department of Labor, Office of Disability Employment Policy, Room S-1313, Constitution Ave., Washington, DC 20210. According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a valid OMB control number. (Paperwork Reduction Act OMB Control Number, 1230-XXXX.)

Note: this information collection sheet is in draft form and is subject to change.