Text Size: A+| A-| A   |   Text Only Site   |   Accessibility

    Shelly Cochran   
503-947-7623   

Bulletins


sign up for email notification
Order or sign up for our subscription services to receive copies of rules, bulletins, and the law book. Signed copies of bulletins are on file at the Oregon Workers' Compensation Division. To obtain a signed copy, contact the Publications Specialist, (503) 947-7627.
 
 
sign up for email notification
Some forms have been created using Microsoft Word and Excel. Be sure to read the help section for tips on how to use the forms.
 
sign up for email notification

Receive updates to this information by e-mail


Bulletin General Subject Form Number
8

Extraterritorial coverage information

Extraterritorial agreement with North Dakota

Extraterritorial agreement with Washington

 
101

Word: 101

Forms to be used in processing initial claims of occupational injury or disease -- Revised 2/07

Relates to OAR 436-060 effective 1/1/08
801 | 3283 | 3283s | 3283r | 3283v |

Word or Excel:
801 | 3283 | 3283s | 3283r | 3283v |
102

Word: 102

Reimbursement from the Retroactive Program -- Revised 9/06

Example of Form 3285

Form 3285 Worksheet

Relates to OAR 436-075 effective 1/2/06
3285 |

Word or Excel:
3285 |
111

Word: 111

Computation of temporary disability, permanent disability, and fatal benefits as related to Oregon's average weekly wage -- Revised 6/07

No related rule
   
112

Word: 112

Reimbursement of injured workers' travel, food, and lodging costs -- Revised 3/08

Relates to OAR 436-009 effective 1/1/08
3921 | 3921s |

Word or Excel:
3921 | 3921s |
124

Word: 124

Required forms and procedures under rules governing vocational assistance (Rev. 11/07) -- Effective 12/1/07

Time Frames to Determine Eligibility and Develop Return-to-Work Plans chart - Rev. 12/07

Relates to OAR 436-120 effective 12/1/07
1081 | 1083 | 1084 | 2800 |

Word or Excel:
1081 | 1083 | 1084 | 2800 |
139

Word: 139

Claim closure -- Revised 6/06

Appeal time frames chart

Body part codes chart (Dates of injury on or after January 1, 2005)

Body part codes chart (Dates of injury prior to January 1, 2005)

Combining impairment values chart

Convert percent to degrees of disability chart

Impairment combining calculator (Excel)

PPD Benefits chart

Relates to OAR 436-030 effective 1/2/08
Relates to OAR 436-035 effective 1/1/08
1503 | 1644 | 1644c | 1644d | 1644p | 1644r | 1644s | 2807 | 2807a |

Word or Excel:
1503 | 1644 | 1644c | 1644d | 1644p | 1644r | 1644s | 2807 | 2807a |
144

Word: 144

Premium assessments -- Revised 7/05

Relates to OAR 436-085 effective 1/2/06
910 |

Word or Excel:
910 |
147

Word: 147

Self-insured surety deposits -- 9/06

Relates to OAR 436-050 effective 11/28/07
824 | 1810 | 3529 | 3640a | 3640b |

Word or Excel:
824 | 1810 | 3529 | 3640a | 3640b |
151

Word: 151

List of authorized vocational rehabilitation providers -- Revised 4/08

Vocational Rehabilitation Provider list updated 4/08

Relates to OAR 436-120 effective 12/1/07
   
162

Word: 162

Oregon workers' compensation proof of coverage (Guaranty Contract) -- Revised 12/07

Relates to OAR 436-050 effective 11/28/07
821 | 3215 | 3216 | 3217 |

Word or Excel:
821 | 3215 | 3216 | 3217 |
170

Word: 170

Lump sum payment of permanent partial disability awards -- Revised 12/07

Relates to OAR 436-060 effective 1/1/08
1174 |

Word or Excel:
1174 |
189

Word: 189

Preferred Worker Program (Rev. 11/07) -- Effective 12/1/07

Example of Form 2344

Preferred Worker Identification Card Example

Relates to OAR 436-110 effective 12/1/07
2190 | 2190s | 2350 | 2350s | 2968 | 2970 | 2971 | 3014 | 3014-extra page | 3293 | 4122 | 4123 |

Word or Excel:
2190 | 2190s | 2350 | 2350s | 2968 | 2970 | 2971 | 3014 | 3014-extra page | 3293 | 4122 | 4123 |
195

Word: 195

Reopening of "Own Motion" claims under ORS 656.278, closure of Own Motion claims, and reimbursement from the Reopened Claims Program -- Effective 1/1/06

Relates to OAR 436-045 effective 1/1/08
1966 | 2066 | 3501 |

Word or Excel:
1966 | 2066 | 3501 |
209

Word: 209

Report of losses instructions and reserving guidelines - Revised - 8/07

Relates to OAR 436-050 effective 11/28/07
2808 | 2809 | 2810 | 2937 |

Word or Excel:
2808 | 2809 | 2810 | 2937 |
220

Word: 220

Medical data reporting -- Revised 8/07

List of insurers required to submit medical billing data updated 6/07

Relates to OAR 436-009 effective 1/1/08
   
227

Word: 227

Form and format for a request for reconsideration -- Revised 12/07

Relates to OAR 436-030 effective 1/2/08
2223a | 2223b | 2223a-s |

Word or Excel:
2223a | 2223b | 2223a-s |
232

Word: 232

Notice of claim acceptance pursuant to ORS 656.262(6) -- Effective 7/15/04

Relates to OAR 436-030 effective 1/2/08
Relates to OAR 436-060 effective 1/1/08
3058 | 3058s |

Word or Excel:
3058 | 3058s |
237

Word: 237

Insurer's report -- Revised 9/02

Relates to OAR 436-060 effective 1/1/08
1502 |

Word or Excel:
1502 |
239

Word: 239

Attending physician's closing examination and report -- Revised 7/98 -- Addendum 7/00

Relates to OAR 436-035 effective 1/1/08
2278 | 2279 | 2312 |

Word or Excel:
2278 | 2279 | 2312 |
247

Word: 247

MCO quarterly reports -- Revised 8/04

Relates to OAR 436-015 effective 1/1/08
   
248

Word: 248

MCO geographical service areas -- Revised 1/07

GSA map

Relates to OAR 436-015 effective 1/1/08
   
251

Word: 251

Change of attending physician or authorized nurse practitioner request -- Revised 1/08

Relates to OAR 436-010 effective 1/2/08
2332 |

Word or Excel:
2332 |
252

Word: 252

Additional independent medical exam request -- Revised 8/07

Relates to OAR 436-010 effective 1/2/08
2333 |

Word or Excel:
2333 |
260

Word: 260

Employer-at-Injury Program, Oregon Administrative Rules 436-105 (Rev. 11/07) -- Effective 12/1/07

Relates to OAR 436-105 effective 12/1/07
2360 |

Word or Excel:
2360 |
273

Word: 273

Instructions for filling out Worker Leasing Notices, Terminations, and Endorsements -- Revised 12/99

Relates to OAR 436-050 effective 11/28/07
2465 | 3270 | 3271 |

Word or Excel:
2465 | 3270 | 3271 |
281

Word: 281

Form 440-2476, "Request for release of medical records for Oregon Workers' compensation claim" -- Revised 9/05

Relates to OAR 436-010 effective 1/2/08
Relates to OAR 436-060 effective 1/1/08
2476 | 2476s |

Word or Excel:
2476 | 2476s |
285

Word: 285

Workers' Compensation Division Request for Hearing, Form 440-2839 -- Revised 10/06

Request for hearing WCD online form

Relates to OAR 436-001 effective 1/17/06
2839 |

Word or Excel:
2839 |
290

Word: 290

Hospital fee schedule - Adjusted cost/charge ratios for Oregon hospitals -- Revised 3/08

Relates to OAR 436-009 effective 1/1/08
   
292

Word: 292

Workers' compensation medical reporting forms -- Revised 12/05

Relates to OAR 436-010 effective 1/2/08
827 | 3245 |

Word or Excel:
827 | 3245 |
293

Word: 293

Form and format for request for administrative review of medical disputes -- Revised 3/07

Relates to OAR 436-009 effective 1/1/08
Relates to OAR 436-010 effective 1/2/08
2842 | 2842a |

Word or Excel:
2842 | 2842a |
294

Word: 294

Overpayment recoveries on reimbursable claims -- Issued 8/96

No related rule
   
297

Word: 297

Review of vocational assistance return-to-work plans -- Issued 8/98

Relates to OAR 436-120 effective 12/1/07
   
307

Word: 307

Spanish translation Form 827-S available -- Revised 3/06

Relates to OAR 436-010 effective 1/2/08
827s |

Word or Excel:
827s |
308

Word: 308

Invasive medical procedures during an independent medical examination (IME) -- Effective 1/1/06

Relates to OAR 436-010 effective 1/2/08
3227 |

Word or Excel:
3227 |
309

Word: 309

Elective surgery response form -- Revised 1/06

Relates to OAR 436-010 effective 1/2/08
3228 |

Word or Excel:
3228 |
310

Word: 310

Spanish language Forms 440-801S (801S), "Reporte de Lesión o Enfermedad en el Trabajo" ("Report of Job Injury or Illness") and 440-3283S (3283S) "Una guia para trabajadores lesionados recientemente en el trabajo" ("A Guide for Workers Recently Hurt on the Job") -- Revised 2/07

Relates to OAR 436-060 effective 1/1/08
801s | 3283s |

Word or Excel:
801s | 3283s |
315

Word: 315

Spanish translations available for correspondence with injured workers -- Revised 12/07

Spanish translation of selected text from Oregon Administrative Rules, Chaper 436

Relates to OAR 436-060 effective 1/1/08
   
316

Word: 316

Claims processing administrative cost factor -- Revised 12/07

Relates to OAR 436-050 effective 11/28/07
Relates to OAR 436-060 effective 1/1/08
Relates to OAR 436-110 effective 12/1/07
   
325

Word: 325

Supplemental disability payment and reimbursement -- Revised 1/05

Calculation sample

Relates to OAR 436-060 effective 1/1/08
3504 | 3530 | 3531 |

Word or Excel:
3504 | 3530 | 3531 |
329

Word: 329

Retention of claims records by insurers and self-insured employers -- Issued 3/24/03

Relates to OAR 436-050 effective 11/28/07
   
337

Word: 337

Provides form to request review of an insurer's classification of a claim as nondisabling -- Effective 2/14/08

Relates to OAR 436-060 effective 1/1/08
2943 | 2943s |

Word or Excel:
2943 | 2943s |
341

Word: 341

Self-insured base rates and election of method used for determination of premium -- Effective 7/1/06 - 6/30/07

Example of completed form 900

Example of completed form 937

Exhibit A - Restrospective rating methods

Exhibit B - Self-insured base rates for fiscal year 7/1/06 - 6/30/07

Plan comparison worksheet

Relates to OAR 436-085 effective 1/2/06
   
342

Word: 342

Determination of "gainful occupation" for permanent total disability (PTD) evaluations -- Revised 2/08

No related rule
   
345

Word: 345

Reporting employer-paid medical deductible claims costs

Relates to OAR 436-060 effective 1/1/08
   
346

Word: 346

Self-insured base rates and election of method used for determination of premium - Effective 7/1/07 - 6/30/08

Example of completed Form 900

Example of completed Form 937

Exhibit A - Restrospective rating methods (Excel 2000)

Exhibit B - Self-insured base rates for fiscal year 7/1/07 - 6/30/08

Plan comparison worksheet (Excel 2000)

Relates to OAR 436-050 effective 11/28/07
Relates to OAR 436-085 effective 1/2/06
900 | 937 |

Word or Excel:
900 | 937 |
347

Word: 347

Retroactive Program benefits -- effective October 1, 2007

Relates to OAR 436-075 effective 1/2/06
   
348

Word: 348

Premium assessment rate -- Effective 1/1/08

No related rule
   

Instructions for use of Workers’ Compensation Division forms created using Microsoft Word or Excel

To customize a Word form, so it will, for example, always include your business name and address, you must unlock it. First, display the Forms toolbar by clicking “View/Toolbars/Forms.” Click once on the lock symbol on the Forms toolbar. Double-click the field (shaded area) on the form that you want to modify and add default text, or delete the form field and replace it with the text you want.

Lock the form again by clicking once on the lock symbol.

IMPORTANT: Do not unlock and relock a Word or Excel form after adding data to it or you will lose all of the data you typed. However, this method may be used to clear a form if you only intend to print and save hard copy.

Forms may print out at more or less than standard size. Please adjust by printing at more or less than 100% according to your needs.



If you have questions about the information contained in this document, please contact Shelly Cochran, 503-947-7623.

 

Get Adobe Acrobat ReaderAdobe Reader is required to view PDF files. Click the "Get Adobe Reader" image to get a free download of the reader from Adobe. Available for Macintosh or Windows.