Bulletins

Bulletins

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.

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.

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 Reader
Adobe 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.

Top of page

Text Only Options

Change the current font size: larger | default | smaller
Current color mode is Black on White, other available modes: Yellow on Black | Black on Cream
Show textual links as buttons
Do not move navbars
Do not alert me when leaving text-mode
Open not handled documents directly
Hide Text Only Options

Open the original version of this page.

Usablenet Assistive is a UsableNet product. Usablenet Assistive Main Page.

State of Oregon

Text Only Options