RETAIN Baseline Participant Form Part 2, revised for Phase 2

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

RETAIN Baseline Participant Form Part 2, revised for Phase 2

OMB: 1230-0014

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OMB Control No.: 1230-0014

Expiration date: 05/31/2022

[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 Enrollment in RETAIN:

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

MONTH DAY YEAR



2. What is the ICD-10 code of the primary injury or illness (write only one ICD-10 code)?



3. Provide a brief description of the injury or illness:



4. Is the primary injury or illness a:

New condition

Worsening of an existing condition


5. Date of Onset of Primary Injury or Illness (date of worsening if not a new condition):

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

MONTH DAY YEAR



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

Yes

No


7. 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



8. 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



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

Agriculture or Mining

Construction or Utilities

Manufacturing

Retail Trade and Wholesale Trade

Transportation and Warehousing

Information (print publishing, software publishing, recording, broadcasting, telecommunications, data processing)

Finance, Insurance, Real Estate, and Leasing

Professional, Management, or Administrative Services (legal, accounting, engineering, design, consulting, R&D, advertising, management of companies, office/business support, facilities/janitorial, travel, temp work, security)

Education

Health Care

Accommodation, Food Services, Arts, and Entertainment

Other Services (repair, laundry, religious or civil organizations, personal care, death care, servants)

Public Administration






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

Management, professional, or related (management, business and financial operations; computer and mathematical; architecture and engineering; life, physical, and social science; community and social service; legal; educational instruction and library; arts; design; entertainment, sports, and media occupations; healthcare practitioners; and technical occupations)

Service (healthcare support; protective; food preparation and serving related; building and grounds cleaning and maintenance occupations; personal care and service occupations)

Sales and office (sales and related; office and administrative support occupations)

Natural resources, construction, or maintenance (farming, forestry, and fishing; construction and extraction; installation, maintenance, and repair occupations)

Production, transportation, or material moving (production; transportation; and material moving occupations)



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, 1230-0014.)


File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorU.S. Department of Labor
File Modified0000-00-00
File Created2021-08-02

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