RTW Coordinator Data Collection Tool

Participant ID Number __________________________

Quarterly Progress Report RTW Coordinator Data Collection Tool

The following form is designed to gather information on key indicators that are required for the DOL Quarterly Progress Report data submissions. This form does not include ALL of the data elements that must be submitted in each QPR, nor is it a requirement to use this form. This form is solely a tool that may be used to collect information on RETAIN worker participants. The form may be used and filled out by any RETAIN project staff – however, the RTW coordinator will likely have the greatest ability to collect and report this information.

Initial and Instances of Communication
Description	Definitions/Instructions	Information/Data
Date of initial communication with worker (RTN22)	Record the date of the initial communication between RTW Coordinator and participant.	________/________/________ Year Month Day
Date of initial communication with worker’s employer (RTN23)	Record the date of the initial communication between RTW Coordinator and the participant’s employer.	________/________/________ Year Month Day
Date of initial communication with worker’s healthcare provider (RTN24)	Record the date of the initial communication between RTW Coordinator and the participant’s healthcare provider.	________/________/________ Year Month Day
Instances of communication with worker participant*(RTN25)	Record the number of instances RTW Coordinator(s) communicated with the worker participant. A communication may include a phone call, in-person meeting, email, or other form of communication.	End of Q1	End of Q2	End of Q3	End of Q4
		________	________	________	________
Instances of communication with worker employer*(RTN26)	Record the number of instances RTW Coordinator(s) communicated with the worker’s employer. A communication may include a phone call, in-person meeting, email, or other form of communication.	End of Q1	End of Q2	End of Q3	End of Q4
		________	________	________	________

Communications and Accommodations
Description	Definitions/Instructions	Information/Data
Instances of communication with worker healthcare provider*(RTN27)	Record the number of instances RTW Coordinator(s) communicated with the worker’s healthcare provider. A communication may include a phone call, in-person meeting, email, or other form of communication.	End of Q1	End of Q2		End of Q3		End of Q4
		________	________		________		________
Instances of communication with workforce professionals* (RTN28)	Record the number of instances RTW Coordinator(s) communicated with a workforce professional. A communication may include a phone call, in-person meeting, email, or other form of communication.	End of Q1		End of Q2		End of Q3	End of Q4
		________		________		________	________
Technical assistance to implement workplace accommodations (RTN29)	Record the number of instances RETAIN staff provided direct technical assistance to employer(s) to implement workplace accommodation(s) for worker participant. Direct technical assistance includes providing a tool, or guiding the employer through tools, resources, planning, or design that supports the implementation of workplace accommodations.	End of Q1		End of Q2		End of Q3	End of Q4
		________		________		________	________
Did the worker’s employer accommodate the worker? (RTN30-34) If accommodations were made, please indicate all that apply For more info, visit: https://www.dol.gov/odep/topics/Accommodations.htm	Examples include: Physical change – installing a ramp or modifying work equipment or the layout of a workspace. Accessible communications and assistive technologies –accessible communication and assistive technologies include accessible computer software, screen reader software, using videophones to facilitate communications, providing sign language interpreters or closed captioning at meetings. Modified work tasks – any change in work tasks or functions such as light-duty assignment. Policy enhancements – modifying a policy to allow a service animal in a business setting or allowing for flexible work schedules. Other accommodations – any accommodation not included in one of the categories listed above.	If accommodations were applied, indicate all that apply below: ☐ Physical change ☐ Accessible communications and assistive technologies ☐ Modified work tasks ☐ Policy enhancements ☐ Other -Describe below __________________________________________ __________________________________________ __________________________________________

Communications, Referrals, Provider Type, and Employment Services

Description

Definitions/Instructions

Information/Data

Date Referred to the Job Accommodation Network (JAN) (RTN35)

Record the date any RETAIN staff referred worker participant or employer to the Job Accommodation Network (JAN).

________/________/________

Year Month Day

Date Referred to an Employee Assistance Program (EAP)

(RTN36)

Record the date any RETAIN staff referred worker participant or employer to any Employee Assistance Program (EAP).

________/________/________

Year Month Day

Date Report of Accident (ROA) Submitted (RTN37)

Record the date a Report of Accident (ROA) was submitted – for workers’ compensation claimants only.

________/________/________

Year Month Day

Date RTW Plan Finalized (RTN38)

Record the date the participant’s Return to Work Plan was finalized. A Return to Work Plan is defined as a plan to support the employee in returning to or staying at work by assessing the ill/injured worker’s barriers to employment and providing ways to overcome them.

________/________/________

Year Month Day

Date of First Follow-up Communication after Worker Participant Returned to Work (RTN39)

Record the date of the first follow-up communication between a RETAIN service provider and the worker participant after the worker’s initial return to work or stay at work after injury/illness.

________/________/________

Year Month Day

Main Provider Type (the type of provider from whom the worker participant receives the majority of his/her care) (RTN40)

☐	Primary Care Physician	☐	Physical Therapist	☐	Mental Health Professional
☐	Occupational Medicine Physician	☐	Chiropractor	☐	Other Physician or Clinician
☐	Physical Medicine and Rehab Specialist	☐	Registered Nurse	☐	Workforce Development Professional
☐	Orthopedic Surgeon	☐	Nurse Practitioner	☐	Vocational Rehab Counselor
☐	Neurosurgeon	☐	Physician Assistant	☐	Other Workforce Professional

Date Referral to Employment Services (RTN41)

Record the date the participant was 1st referred to employment-related services while enrolled in RETAIN. If the participant was not referred to employment-related services, leave this field blank.

________/________/________

Year Month Day

Date Participant Began Any Employment Services (RTN42)

Record the date the participant 1st began employment-related services while enrolled in RETAIN. If the participant has not received any employment-related services, leave this field blank.

________/________/________

Year Month Day

Labor Market Outcomes and Participation Status
Description	Definitions/Instructions	Information/Data
Date Participant Began Absence from Work (RTN52)	Record the date the participant began an absence from work. If the participant did not experience an absence from work, leave this field blank	________/________/________ Year Month Day
Work-Loss Days (RTN53)	Record the total number of work-loss days the participant experienced while enrolled in RETAIN.
Days of Restricted Work Activity (RTN54)	Record the total number of days of restricted work activity the participant experienced while enrolled in RETAIN Work restriction cases occur when an employer or health care professional keeps, or recommends keeping, an employee from doing the routine functions of his or her job or from working the full workday that the employee would have been scheduled to work before the injury or illness occurred.
Date of Return to Work (RTN55)	Record the date the participant returned to work. If the participant has not returned to work, leave this field blank.	________/________/________ Year Month Day
Number of Hours Worked Upon Returning to Work (RTN56)	Record the number of hours per week the participant worked upon returning to work. If the participant has not returned to work, leave this field blank.
Return to Work Job and Employer (RTN57)	☐ 1 = Participant returned to pre-injury/illness job ☐ 2 = Participant returned to work in a different job with the pre-injury/illness employer ☐ 3 = Participant returned to work with a different employer, not the pre-injury/illness employer ☐ 9 = Participant has not returned to work
RETAIN Participation Status (RTN58)	☐ 1 = Participant is enrolled in RETAIN ☐ 2 = Participant has exited RETAIN
Date of Exit from RETAIN (RTN59)	Record the date the participant exited RETAIN. If the participant is still enrolled in RETAIN and receiving RETAIN services, leave this field blank.	________/________/________ Year Month Day
Referral to Services Beyond RETAIN After 6 Months (RTN60)	☐ 1 = Participant did not return to work within 6 months of enrolling in RETAIN and was referred to services beyond RETAIN ☐ 2 = Participant did not return to work within 6 months of enrolling in RETAIN and was not referred to services beyond RETAIN ☐ 9 = Participant is still enrolled in RETAIN and is receiving RETAIN services

*Record data from the RETAIN Return to Work Coordinator Communications Log

RETAIN Return to Work Coordinator Project Log

(RTN22 – RTW28) RTW Communications with Stakeholders: This Table may be used to document each instance of communication with the worker participant and related stakeholders. At the end of each column, record the total number of communications for each communication type. Find the sum of these four columns and enter this total on form 3.2 Return to Work Coordinator Services Data Form (RTN22 – RTN28).

Date	Communication Type				Stakeholder
	Phone	Email	In-person meeting	Other (describe)	Worker Participant, Employer, Primary Healthcare Provider	Brief description of contact (e.g. discussed accommodations, first/second follow-up communication after RTW)
Total

RETAIN

0