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REQUIRED FORMS FOR STAY AT WORK FUNDING

  1. ACCESS THE PROGRAM ONLINE - Use your existing Secure Access Washington account and log in through the My L&I Portal. At your ‘Dashboard’ screen, choose Request Light Duty Wage Reimbursement to start the process and follow up on dollars requested and received.
  2. ACTIVITY PRESCRIPTION FORM (F242-385-000) - This standard medical provider form allows a worker to return to work after an injury. May include mandatory time off, weight and motion restrictions, or release to full duty. 
  3. EMPLOYERS JOB DESCRIPTION AND RELEASE FORM- LIGHT DUTY (WFC 252-040-000-LD). OPTIONAL: JOB ANALYSIS - LIGHT DUTY (WFC 252-072-000-LD) This form is a summary of Light Duty tasks firefighter will perform. The WFC version can also serve as an Employee offer and acceptance of Light Duty Work. This form may be used as by the health care provider to release a firefighter for light duty for day or 24 shifts. 
  4. STAY AT WORK WAGE REIMBURSEMENT APPLICATION FOR EMPLOYERS (F243-001-000): Fire Departments must also include:
    • Timecards and Payroll Stubs • Activity Prescription Form
    • Employer Description of Job Full Duty Form WFC 252-040-000-FD.
    • Employer Description of Job and Light Duty Job Offer Form WFC 252-040-000-LD. 
  5.  STAY AT WORK EXPENSE FORM (F243-003-000): Form used to request reimbursement of up to $2500 per injured worker for equipment used for light duty modifications. Must be submitted with :
    • Receipt for Equipment Purchased
    • Brief Rational of Purchase for Injured Worker

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About This Project

Funding and support for this project has been provided by the State of Washington, Department of Labor & Industries, Safety & Health Investment Projects

AFTER THE INJURY: STEPS TO RETURN

  1. Firefighter promptly reports injury to Chief, officer or human resource department to start the return to work process. L&I or self insurance claim is generated and accident report form is filled out using lni.wa.gov/filefast or by department policy. A claim number is usually generated. 

  2. Chief or Officer sends firefighter to health care provider with a return to work package. This usually includes the department’s SOG or SOP with return to work instructions, Job Analysis and Job Description forms for both Full and Light Duty. 

  3. After examination, the Health Care Provider signs an Activity Prescription Form for: A) Release for full duty based on the Full Duty Job Description Form. B) Release for Light duty on Light Duty Job Description form. C) Injured firefighter is not released for any work at the time.

  4. Firefighter is offered a light duty position which must be approved by his or her Health Care Provider on the Light Duty Job Description Form or by letter. The Stay at Work Program may reimburse departments for up to 50% of light duty wages paid for up to 66 days ($10,000 maximum).

  5. After a period of recovery time, firefighter is reassessed by Health Care Provider and the assessment in step 3 is repeated. If cleared to return to work, Firefighter is released on Full Duty Job Description Form.

  6. If injury caused an extended absence, Training Officer has firefighter complete re-entry program and verifies full duty readiness. The program is designed to make the transition back to full duty and reduce skill degradation.

  7. FIREFIGHTER IS RETURNED TO FULL DUTY!
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