Free F207-191-000 Self Insurance Continuing Education Report of Course Completion - Washington


File Size: 152.6 kB
Pages: 2
Date: April 28, 2009
File Format: PDF
State: Washington
Category: Workers Compensation
Author: FORMS AND RECORDS MANAGEMENT
Word Count: 642 Words, 4,832 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.lni.wa.gov/forms/pdf/207191af.pdf

Download F207-191-000 Self Insurance Continuing Education Report of Course Completion ( 152.6 kB)


Preview F207-191-000 Self Insurance Continuing Education Report of Course Completion
MAIL COMPLETED FORM TO:
Department of Labor and Industries Self Insurance Section PO Box 44890 Olympia, WA 98504-4890 [email protected]

Self Insurance Continuing Education Report of Course Completion
Course with department ID # Course without department ID # Teaching and/or Course Preparation Credit

Check the appropriate box: (see page 2 for explanation)

Today's Date: ____________________ Course Date(s): Attendee Name: ________________________________________________________________ Address: ______________________________________________________________________ Phone number: ____________________ Employer name and work location: Course ID #:
(Course number if pre-approved by L&I.)

E-mail address:

Course Title:

Sponsor's Name: _______________________________________________________________
(Organization that sponsored the course, if any)

Instructor(s) Name: _____________________________________________________________ Course location: _______________________________________________________________
(Name and physical address of location)

Class hours (excluding introduction, lunch and break times): To what category do you want your credits applied? __________________________________ Claims process/procedures Legal Medical Ethics Elective

Either a copy of the signed certificate of completion must be attached OR the shaded area below must be completed by the sponsor/instructor. SPONSOR/INSTRUCTOR VERIFICATION OF COURSE COMPLETION
I certify that the class information provided above is true and correct. Any changes made will be provided to the Self Insurance Department promptly. _____________________________________________________ Original Signature of Sponsor/Instructor _____________________________________________________ Printed Name of Sponsor/Instructor ______________________ Date ______________________ Contact Phone #

F207-191-000 ce report of course completion 03-2009

RESET

Self Insurance Continuing Education Information and Instructions for Report of Course Completion
This form is used by department-approved claims administrators to report course completion for obtaining continuing education credit. To determine the appropriate box (on front page): · Check the first box if the course was pre-approved by the Department of Labor and Industries (L&I) and assigned continuing education credits. · Check the second box if you attended a course independently and are requesting assignment of credit. Do not use this option if the sponsor has requested / will request course approval. · Check the third box if you are requesting credit for teaching a course and/or preparing a course. If you check either the second or third box, your request will be reviewed by the Curriculum Review Committee and you will be notified of approval or denial. If this is a credit request for post-approval of a class that does not yet have credits assigned by the department, you must attach a detailed description of the course content and handouts. Post approval requests must be received within 60 days of course completion. If this is a credit request for authoring new course materials or teaching a course, please attach: · An agenda showing detailed time allotments · A detailed description of the course content · A description of the training method(s) to be used · A copy of course texts, references and handouts. Credit can be given on a one time basis per course. Credit Category: Check the appropriate box. Categories are defined as follows: Claims process/procedures: Instruction on any complex claim adjudication activity which is not specific to the "Legal" or "Medical" category. (Examples: Complex benefit calculations; vocational issues; etc.) Effective communication skills and relationship building with workers, their representatives, physicians, and the Department. Legal: 1) Case law: Primarily, instruction on new case law as it is handed down. Classes on existing case law may be considered on a case-by-case basis, depending on complexity. Credit will not be awarded for basic classes on established case law. 2) Statutory changes: Instruction on recent changes to Title 51. ("Recent" means within one year of the effective date of the legislation.) Medical: Instruction on complex medical issues related to the adjudication of claims under Title 51. (Examples: Study of specific medical conditions and their standard courses of treatment; Medical case management in complex or multiple injury claims; etc.) Ethics: Instruction about values, principles, professional conduct, etc., as it relates to workers' compensation. Elective: Additional instruction in one or more of the above categories; or, instruction on industry-specific issues related to workers' compensation, safety and prevention, disability, etc.
F207-191-000 ce report of course completion 03-2009