Minnesota Department of Labor and Industry Workers Compensationdivision

Minnesota Department of Labor and Industry Workers’ CompensationDivision

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Enterdates in MM/DD/YYYYformat.

This form must be provided to the employee. (Minn. Rules 5221.0410,l subd. 6)

ReportofWorkAbility

See Instructionsof ReverseSide

R W 0 1

DO NOTUSETHIS SPACE

NOTICE TO EMPLOYEE:YOU MUST PROMPTLY PROVIDEACOPYOF THISREPORT TO YOUR EMPLOYER ORWORKERS’ COMPENSATION INSURER,AND QUALIFIED REHABILITATION CONSULTANT IF YOUHAVE ONE.

WID or SSN
000-00-0000 / DATE OF INJURY
EMPLOYEE
EMPLOYER
INSURER/SELF-INSURER-TPA
INSURER CLAIM NUMBER

Date of most recent examination by this office

Selecttheappropriateoption(s)belowandfillintheapplicabledates.

1.Employeeisabletoworkwithout restrictions asof(date)

2.Employeeisabletoworkwithrestrictions,from(date)to(date)

Therestrictionsare:

3.Employee isunable to work from(date)to(date)

The next scheduled visit is:asneeded OR

NAME (Typeor Print) / SIGNATURE / DEGREE
ADDRESS / STATE / LICENSE #/REGISTRATION#
CITY / STATE / ZIP CODE / PHONE # (include area code) / DATE SIGNED

MNRW01(7/10)

INSTRUCTIONS FORCOMPLETING REPORT OFWORK ABILITY

Eachhealthcareproviderdirectingthecourseoftreatmentforanemployeewhoallegestohaveincurredaninjuryonthejob mustcompleteaReportofWorkAbilitywithin10daysofarequestforaReportofWorkAbilityfromtheinsurer,oratthe applicableinterval(Minn.Rules5221.0410,subp.6):

1.every visit if visits arelessfrequent that one every two weeks;

2.every2 weeks if visits aremore frequent than onceeverytwoweeks,unlessworkrestrictionschange sooner;and

3.uponexpirationoftheendingorreviewdateoftherestrictionsspecifiedin a previous Report of Work Ability. TheReportofWorkAbilitymusteitherbeonthisformorinareportthatcontainsthesameinformation. TheReportofWork

Ability must:

•Identify the employee byname and date of injury.

•Identify the employer at the time of theemployee’sclaimedworkinjury.

•If known, identify the workers’ compensation insurer at the time of the claimed injury, or the workers’ compensation third-party administrator.Also indicatethisworkers’compensationpayer’s claimnumber.

•Indicatethedateofthemostrecentexaminationbythisoffice. TheReportofWorkAbilityshouldbecompleted based on this evaluation.

•Identifytheappropriateoptionwhichbestdescribestheemployee’scurrentabilitytoworkbycheckingbox1,2, or3.

1.If the employee is able to work without restrictions,fillinthebeginningdate.

2.Iftheemployeeisabletoworkwithrestrictions,fillinthedateanyrestrictionofworkactivityistobeginand theanticipatedendingorreviewdate.Describeanyrestrictionsinfunctionalterms(e.g.,employeecanlift upto20pounds,15timesperhour;shouldhave10minutebreakeveryhour).

3.Iftheemployeeisunabletoworkatall,fillinthedatetherestrictionofworkactivityistobeginandthe anticipatedendingor review date.

•Indicate thedate of the next scheduled visit or indicatethat additional visits willbe scheduledas needed.

•Identifythehealthcareprovidercompletingthereportbyname,professionaldegree,licenseorregistration number,addressandphonenumber.

•Include the signature of the health careprovider anddateofthereport.

Thehealthcareprovidermustprovidethe Report of Work Ability to the employee and placea copy in themedical record.

Ifyouhavequestions,pleasecalltheclaimrepresentativeortheDepartmentofLaborandIndustry,Workers’Compensation Divisionat(651)284-5030or1-800-342-5354.

Thismaterialcanbemadeavailableindifferentforms,suchaslargeprint,Brailleoronatape.Torequest,call(651)284-5030or 1-800-342-5354 (DIAL-DLI) Voice orTDD (651) 297-4198.

ANYPERSONWHO,WITHINTENTTODEFRAUD,RECEIVESWORKERS’COMPENSATIONBENEFITSTOWHICHTHEPERSONISNOTENTITLEDBYKNOWINGLYMISREPRESENTING,MISSTATING,ORFAILINGTODISCLOSEANYMATERIALFACTISGUILTYOFTHEFTANDSHALLBESENTENCEDPURSUANTTOSECTION609.52,SUBDIVISION3.