RETAIN Baseline Participant Form Part 2, revised for Phase 2

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:

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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):

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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.)