Free F413-062-000 cholinesterase monitoring reimbursement request - Washington

Mail completed form(s) and documentation to: Department of Labor and Industries PO Box 44610 Olympia WA 98504-4610
type

Cholinesterase Monitoring Reimbursement Request
Date submitted
Phone number State ZIP+4

Please type or print legibly
For more information about completing this form, contact L&I at (360) 902-5436 or (1-800) 4 BE-SAFE (423-7233) Name of company Contact person Address Name of individual completing form Signature of individual completing form
City

Taxpayer ID number

I certify that only actual costs incurred are being submitted for reimbursement.

TOTAL COSTS
1. 2.

L&I must have a signed W-9 with your tax ID number to process payment

Medical monitoring costs: Travel costs for medical and training (37.5 ¢ per mile) Training costs: Recordkeeping costs:

$ $ $ $

3. 4.

DOCUMENTATION REQUIRED AND INSTRUCTIONS
1.

Medical monitoring costs: Medical costs associated with the required cholinesterase monitoring program including consultations, follow-up visits and procedures, blood draws, and laboratory testing costs Required Documentation: A copy of receipts or invoices from the medical provider(s). Name and location of the medical provider (if not legible on receipt/invoice). Attach a list of the employees participating. You may also use this list for travel, training, and recordkeeping information.

2.

Travel for medical and training: Required Documentation: Provide name and location of clinic. Provide roundtrip miles from your worksite to clinic. Provide name and location of training provider (if applicable). Provide roundtrip miles from your worksite to the training location (if applicable). Provide the means of transportation for each employee, which employees traveled together, and dates of travel.

3.

Training costs: Only the portion of training required by the Cholinesterase Monitoring rule is eligible for reimbursement. Required Documentation: Listing of employees trained, length of cholinesterase monitoring training, and person conducting the training. Pay rate of the trainer (if training is done by your employee). Pay rate of each employee who attended training. A copy of receipts or invoices for vendor conducted training (if you paid a vendor to conduct training on cholinesterase monitoring).

4.

Recordkeeping costs: This is limited to recording handling hours. This does not include the preparation of spray records or other records not specifically required by the Cholinesterase Monitoring rule. Required Documentation: Name and pay rate of person(s) performing recordkeeping. Actual hours worked performing recordkeeping duties.

F413-062-000 cholinesterase monitoring reimbursement request 5-2007