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Title/Description: Type, Number, Alt Lang:
Employer’s Guide to the Hazard Communication Rule  

Booklet: Washington State''s new Hazard Communication rule became effective April 15, 2013. It is intended to improve understanding of hazard information found on product labels. The booklet includes training requirements, a Q&A about who is covered, pictograms, descriptions of hazards and everything employers need to know and do to be in compliance.

The changes are based on the International Globally Harmonized System of Classification and Labeling of Chemicals (GHS).

 Publication
 F413-012-000
¿Lesionado por un tercero? Usted tiene opciones legales

Folleto: Un resumen de los derechos legales y opciones que tiene un trabajador lesionado si una acción contra un tercero está relacionada con su reclamo de compensación para los trabajadores. Incluye el Formulario de elección contra terceros que debe ser completado por el trabajador. Aviso. El formulario debe imprimirse, firmarse y enviarse por correo.

 

 Form
 F249-008-999
¿Lesionado por un tercero? Usted tiene opciones legales

Folleto: Un resumen de los derechos legales y opciones que tiene un trabajador lesionado si una acción contra un tercero está relacionada con su reclamo de compensación para los trabajadores. Incluye el Formulario de elección contra terceros que debe ser completado por el trabajador. Aviso. El formulario debe imprimirse, firmarse y enviarse por correo.

 

 Publication
 F249-008-999
 Safety Standards for WAC 296-56 - Longshore, Stevedore and Waterfront Related Operations

The rules included in this chapter apply to any and all waterfront operations for longshore, stevedore and waterfront  related operations, cargo handling, and related terminal operations and equipment under the jurisdiction of the  Department of  Labor and  Industries.

 Manual
 F414-034-000
2005 Annual Report - Department of Labor & Industries

Provides a statistical overview of results achieved in fiscal year 2005 (July 1, 2004, through June 30, 2005), budget information and a narrative introduction to the Department of Labor and Industries.

 Publication
 F101-068-000
2007 Annual Report - Department of Labor & Industries

Provides a statistical overview of results achieved in fiscal year 2007 (July 1, 2006, through June 30, 2007), budget information and a narrative introduction to the Department of Labor & Industries.

 Publication
 F101-080-000
2008 Annual Report - Department of Labor & Industries

Provides a statistical overview of operations in fiscal year 2008 (July 1, 2007, through June 30, 2008), budget information and a summary of accomplishments during the fiscal year.

 Publication
 F101-089-000
2008 Annual Report for the Washington State Fund: Washington''s State-run Workers'' Compensation Program

Book: Introduces Washington State''s Workers'' Compensation Program, including rate-setting and investment policies, financial statement overview, and services available to help employers control workers'' comp costs.

 Publication
 F101-086-000
3 Cosas que Debe Conocer Sobre la Red de Proveedores Médicos de L&I

Volante: Le explica a los trabajadores la información básica sobre la Red de Proveedores Médicos de L&I. La volante la pueden utilizar los trabajadores cubiertos por L&I y por las empresas autoaseguradas.  Se aplica a los trabajadores en el estado de Washington.  Incluye información para comunicarse por la Internet y el número de teléfono.  

 Publication
 F242-406-999
3 Things to Know about L&I''s Medical Provider Network

Handout: Explains to workers the basic information about L&I’s Medical Provider Network. The handout can be used with workers covered both by L&I and by self-insured employers. Applies to workers in Washington state. Includes website and phone number contact information.

 Publication
 F242-406-000
A Guide to Workers'' Compensation Benefits For Employees of Self-Insured Businesses

Pamphlet/booklet: Explains to employees of self-insured businesses their rights and responsibilities under industrial insurance law. Describes benefits and how to file a claim.

 Publication
 F207-085-000
A Guide to Workplace Safety and Health in Washington State

Pamphlet/booklet: Provides an overview of the Washington Industrial Safety and Health Act (WISHA), worker and employer rights and responsibilities, enforcement of WISHA rules, and consultation and education services L&I provides. Previously titled A Guide to WISHA

 Publication
 F416-132-000
Access Authorization for External Access to Apprenticeship Registration and Tracking System (ARTS)

Form must be filled out to request access to Apprenticeship Registration and Tracking System (ARTS).

 Form
 F100-535-000
Account Deposit for Contractor''s or Miscellaneous Account Holder''s

Used to deposit money into your L&I account (Electrical).

 Form
 F500-080-000
Account Deposit for Factory Assembled Structures Account Holders

You must have a contractor license number or have completed an application for a miscellaneous account to use this form.

 Form
 F622-081-000
Accountability Agreement - (Spanish) Acuerdo de Responsabilidad

Este documento proporciona los datos necesarios para tomar una decisión informada con referencia a los beneficios de capacitación vocacional y explica las responsabilidades que usted y su consejero vocacional (VRC, por su sigla en inglés) tienen.

 Form
 F280-016-999
Accountability Agreement

This document provides the facts necessary to make an informed decision regarding vocational retraining benefits and explains the responsibilities you and your vocational counselor (VRC) have. For OJT retraining plans, please refer to form F280-029-000.

 Form
 F280-016-000
Acuerdo de propiedad de Herramientas y Equipo para el Plan de Formacion Profesional

El trabajador lesionado está de acuerdo con los términos de propiedad de las herramientas y/o el equipo comprado como parte de su plan de capacitación de L&I.

 Form
 F245-351-999
Adaptacion Previa al Trabajo Solicitudad de Ayuda

Este formulario puede utilizarlo un terapeuta o proveedor vocacional para solicitar una modificación de empleo para un trabajador lesionado antes de que el trabajador lesionado sea empleado, posiblemente en un programa de capacitación.  Esto puede incluir herramientas y equipo comprado por L&I.



 Form
 F245-350-999
Address Change Request for Injured Workers - (Spanish) Solicitud para cambio de dirección para trabajadores lesionados

Para ser completada y firmada por un trabajador lesionado del fondo estatal para notificarle a L&I de un cambio de dirección.  Todos lo cambios de dirección deben someterse por escrito y estar firmados por el trabajador lesionado.

 Form
 F242-388-999
Address Change Request for Pensioners - (Spanish) Solicitud para cambio de dirección para pensionados

Utilizado por el pensionado para notificarle a L&I de una nueva dirección postal.  L&I debe recibir este formulario para el primer día del mes para que el pago mensual pueda recibirse a tiempo.

 Form
 F242-107-999
Address Change Request for Pensioners

Used by the pensioner to notify L&I of a new mailing address. L&I must receive this form by the first day of the month so your monthly payment is received in a timely manner.

 Form
 F242-107-000
Administrative Rules - Chapter 296-27, 350 & 360 WAC & RCW 49.17

These WAC and RCW rules explain the record keepkeeping responsibilities of businesses such as medical providers, employers who handle biohazards, etc.

 Manual
 F414-037-000
Administrator / Electrician / Master Electrician Certificate Renewal

To renew your electrical certificate. Fee varies depending on renewal type.

 Form
 F500-045-000
Adolescentes en el trabajo

Panfleto/folleto: Responde a preguntas que los empleadores, padres y adolescentes podrían tener cuando contratan trabajadores adolescentes (edades 14-17). Explica las reglas de trabajo no agrícolas, incluyendo los permisos necesarios, horas y condiciones de trabajo. Proporciona enlaces para otros recursos.

 Publication
 F700-022-999
Affidavit for Time Loss Compensation Benefits

Completed by injured workers contending eligibility for payment of back time loss benefits for a period that exceeds six months or $25,000. Injured workers requesting benefits for current time missed from work due to a work-related injury should use the F242-052-000 Worker Verification Form.

 Form
 F242-395-000
Affidavit of Continuity Medical Gas Installation

Affidavit of Continuity

 Form
 F627-043-000
Affidavit of Experience - Plumbers

This form is required to report plumber trainee''s plumbing experience for credit towards journey level or specialty status.

 Form
 F627-004-000
Affidavit of Experience

This affidavit is used to record the hours of a trainee''s electrical experience with direct supervision under a Washington certified journeyman, master or specialty electrician.

 Form
 F500-043-000
Affidavit of Wages Paid - Public Works Contract and Instructions

This form is a fillable Word document that is used by a contractor, company or agency to show the wages paid to employees on a public works project. The best way to use this document is to bookmark this page as a “Favorite” in your web browser. Then each time when you want to use the document, access the online version of the form. This will ensure you are always utilizing the most recently published form. (We recommend you not download the document and save the form for future use because we may make changes to the form that your downloaded version will not contain.) You must file the Affidavit of Wages Paid form when you have completed your portion of a public works job/project. Addendum A is form number F700-161-000, Addendum C is form number F700-162-000, and the EHB 2805 (RCW 39.04.370) Addendum is form number F700-164-000.

 Form
 F700-007-000
Affidavit of Wages Paid Addendum A Additional List of Crafts

Please use this addendum to list additional Crafts/Trades/Occupations when filing an Affidavit of Wages of Paid and you need to list more Crafts/Trades/Occupations than the Affidavit of Wages Paid form can accommodate. This is the addendum A to form F700-007-000.

 Form
 F700-161-000
Affidavit of Wages Paid Addendum B List of Next Tier Subcontractors - Public Works Contract

Copies of the 05-2008 version will be available in the warehouse later in July.

 Form
 F700-143-000
Affidavit of Wages Paid Addendum C Additional Information

Please use this addendum to provide any additional information you want to communicate to L&I when you file an Affidavit of Wages of Paid. Addendum C is for form F700-007-000.

 Form
 F700-162-000
Affidavit of Wages Paid Addendum D

Please use this addendum to provide the details of the Apprentices associated with your Affidavit of Wages of Paid. Addendum D is for form F700-007-000.

 Form
 F700-165-000
Affidavit to Release Public Records

This form is to request L&I to release public records in the contractors registration section.

 Form
 F625-066-000
Affidavit_for_Time_Loss_Compensation_Benefits (Spanish) Declaración Firmada para Compensación de Tiempo Perdido

Para ser completada por los trabajadores lesionados que reclaman que tenian derecho a recibir el pago de beneficios de tiempo perdido no pagados anteriormente por un periodo que excede seis meses o $25,000.  Los trabajadores lesionados que soliciten beneficios por el tiempo perdido de trabajo actual debido a una lesión relacionada con el trabajo deben usar el Formulario de verificación de empleo, F242-052-999.

 Form
 F242-395-999
Agreement - Farm Labor Contractors and Workers - Spanish - Acuerdo entre Contratistas Agrícolas y Trabajadores

Acuerdo con los contratistas agrícolas y trabajadores sobre salarios de empleo y condiciones 

 Form
 F700-046-999
Agreement - Farm Labor Contractors and Workers

Employment wages and conditions agreement with Farm Labor Contractors and Workers

 Form
 F700-046-000
Agreement of Assumption and Guarantee of Workers'' Compensation Liabilities (Certified Self-Insurer)

Used by certified self-insured companies when they are acquired by another organization. New parent organization guarantees the self-insured workers'' compensation liabilities of its new subsidiary.

 Form
 F207-040-001
Agreement of Assumption and Guarantee of Workers'' Compensation Liabilities - Application of Certification

Used by an employer to apply for self-insurance.

 Form
 F207-040-000
Agricultural Employer Worksheet

Used by agricultural employers to assist them in determining if they are following the state Agricultural Employment Standards and the Minimum Wage Act for their employees.

 Form
 F700-125-000
Agricultural Employment Standards - Chapter 296-131 WAC (Spanish) Estándares de Trabajo Agrícola

Estándares de trabajo agrícola - Capítulo 296-131 del Código Administrativo de Washington (WAC, por su sigla en inglés)

 Manual
 F700-085-999
Air Conditioner/Heat Pump Pre-Inspection Checklist

This checklist is designed to be generic in content and may not include all requirements for your particular installation.

 Form
 F622-014-000
Alleged Safety Or Health Hazards (DOSH Complaint Form) Spanish - Presuntos Riesgos de Salud y Seguridad (Formulario de Queja de DOSH)

Los empleados usan este formulario de queja para reportar las condiciones de trabajo que ponen en peligro la seguridad y salud de los trabajadores.

 Form
 F418-052-999
Alleged Safety Or Health Hazards (DOSH Complaint Form)

Employees use this form to report work place conditions which jeopardize workers safety and health.

 Form
 F418-052-000
Alteration Fire Safety Pre-Inspection Checklist -Spanish Lista de Comprobación para la Preinspección de Seguridad contra Incendios

Lista de comprobación para dueños de casas sobre cómo mejorar sus casas antes de la preinspección de HUD para alcanzar los estándares en el área de seguridad contra incendios.

 Form
 F622-011-999
Alteration Fire Safety Pre-Inspection Checklist

Checklist for homeowners on how to upgrade their pre-HUD homes to approach the HUD standards in the area of fire safety.

 Form
 F622-011-000
Alteration Polybutylene Re-Pipe Pre-Inspection Checklist

This checklist is used by the contractor when altering a polybutylene re-pipe. Be sure you can answer YES to all questions before calling L&I for an inspection.

 Form
 F622-053-000
Alteration Re-Roofing for Low Slope Roofing

Checklist used by the contractor when altering a low slope roof.

 Form
 F622-039-000
Always Wear Eye Protection / Siempre Use Protección para los ojos (English/Spanish)

Picture of a large eye with some content on when to use eye protection. Get poster printing tips.

Fotografía de un ojo grande con contenido sobre cuando debe usar protección de los ojos. Obtenga información sobre cómo imprimir carteles.

 Poster
 FSP0-940-999
Always Wear Eye Protection

Sticker: 7.25 inches X 4.25 inches.

 Sticker
 FSP0-941-000
Amendment of Irrevocable Standby Letter of Credit

Used by a self-insured employer to change items on the surety document such as amount of letter of credit issued as collateral.

 Form
 F207-112-111
An Annual Electrical Permits Saves Time and Money. Would it Work for You?

Flier: Describes when facility operators/owners qualify for an annual electrical permit.

 Publication
 F500-123-000
An Employer''s Intro to L&I

Info card: Provides information on the Employer''s Intro to L&I workshop, including statewide schedule of workshops. Designed for employers and managers, the workshop covers a number of topics, including workers'' compensation insurance, workplace safety, and overtime.

 Publication
 F101-101-000
Annual Supplemental Surety Information

Used by self-insured employers to assist in fulfilling surety requirements.

 Form
 F207-125-000
Aplicando para su Licencia de Negocio en Washington: Una Guía Detallada

Panfleto: Breve, panfleto fácil de leer que explica los pasos a seguir para solicitar una licencia de negocio y lo que necesita hacer si planea contratar empleados. Incluye cómo presentar una solicitud para registrarse como contratista de construcción.

 Publication
 F101-079-999
Application / Renewal for an Electrical Training Certificate

This the application for an Electrical Training Certificate or the renewal of. (This does NOT make you a registered apprentice).

 Form
 F626-048-000
Application for a 0% Supervision Modified Electrical Training Certificate & Specialty Examination

Covers 03A, 06B, 07A, 07B, 07C, 07D, 07E, and 10 specialty licenses.

 Form
 F500-097-000
Application for Accreditation Cranes/Derricks and other Material Handling Devices

Application to become an accredited crane certifier.

 Form
 F416-063-000
Application for Accreditation of Engineer to Approve Industrial Utilization Equipment

Used by an Engineer to apply for accreditation by L&I to approve unlisted equipment.

 Form
 F500-101-000
Application for Agent On-Line Insurance Entry Account

Application for Agent On-Line Insurance Entry Account

 Form
 F625-110-000
Application for Amusement Ride Inspector Certification

Application to be certified as an amusement ride inspector.

 Form
 F500-065-000
Application for Amusement Ride or Air Supported Structure Operating Permit

To apply for a decal for an amusement ride or air supported structure.

 Form
 F500-010-000
Application for Apprenticeship

EXAMPLE ONLY: Example of an application to apply for an apprenticeship. Registered Apprenticeship Programs use their own forms. NOT TO BE USED TO REQUEST PLUMBER or ELECTRICAL TRAINEE CARD.

 Form
 F100-033-000
Application for Asbestos Contractor Certification

Contractors use this form to apply to be a certified asbestos contractor in Washington state.

 Form
 F413-007-000
Application for Backflow Specialty Exam

This form is used to apply for the backflow specialty examination.

 Form
 F627-035-000
Application for Backflow Trainee Certificate

This form is used to apply for a backflow trainee certificate.

 Form
 F627-033-000
Application for Benefits - Crime Victims

Used by victims of a crime in Washington State to receive benefits for time lost from work, loss of financial support, medical or mental health treatment. The Spanish version of the instructions are online as F800-042-999.

 Form
 F800-042-000
Application for Benefits- Crime Victims Spanish - Instrucciones para: Solicitud para Beneficios para Víctimas de Crimen

Instrucciones en español para completar el formulario F800-042-000, Solicitud para beneficios para víctimas de crimen.  El formulario es utilizado por víctimas de crimen en el estado de Washington para recibir beneficios de tiempo perdido del trabajo, pérdida de apoyo económico, tratamiento médico y de salud mental.  Esta versión del 10 de diciembre está en Internet solamente.

 Form
 F800-042-999
Application for Certificate of Competency as an Inspector of Pressure Retaining Items

To apply for a certificate of competency as an Inspector of Pressure Retaining items. You can only mail or fax this form to L&I. Emailed forms are not accepted. NOTE: Applications MUST be received no later than 30 days prior to the exam date. Incomplete applications WILL NOT be accepted.

 Form
 F620-040-000
Application for Charter Boat Operators License

Use this form to apply for an operators license of a charter vessel.

 Form
 F416-034-000
Application for Construction Contractor Registration

This is the form you would complete to register as a construction contractor.

 Form
 F625-001-000
Application for Copies of Citation and Notice

Used by an employee to apply for copies of citation and notices issued to their employer.

 Form
 F418-023-000
Application for Elective Coverage - Sole Proprietor, Partners, For-Profit Corporate Officers, or Member/Managers of Limited Liability Company (LLC)

Used by employers to apply for workers'' compensation coverage for non-mandatory employment. Shows a list of categories of employment that are not considered mandatory to have workers'' compensation.

 Form
 F213-042-000
Application for Elective Coverage of Excluded Employments

Used by employers to request coverage of workers'' compensation for non-mandatory employment. Shows a list of employment categories to choose from that are not included within the mandatory coverage of workers'' compensation.

 Form
 F213-112-000
Application for Electrical Contractors License

Application used to get an electrical contractors license

 Form
 F500-018-000
Application for Electrician Examination

Application and instructions for a Washington State electrician''s certificate examination.

 Form
 F626-001-000
Application for Exclusion/Inclusion - Mandatory Coverage (Family Farm)

To exclude or include coverage for a family farm''s children.

 Form
 F213-113-000
Application for Farm Internship

Application form: Small farm owners wishing to participate in the pilot small farm internship program must complete this form and submit it to the department. The information requested on the form is required to process an application for approval in order to issue a certificate of participation.

 Form
 F700-158-000
Application for Farm Labor Contractor License

Used to apply or renew a license.

 Form
 F700-014-000
Application for Group Retrospective Rating

Used by organizations to set up an agreement with L&I authorizing their participation in retrospective rating.

 Form
 F250-004-000
Application for House to House Sales Sales Employer Registration Certificiate

Used by employers to register as employing minors who will be engaged in house-to-house sales, as required by WAC 296-125-024, with Labor and Industries.

 Form
 F700-121-000
Application for Insignia Conversion Vendor/Medical Units

Used to apply for an official insignia for conversion vendor or medical unit factory-assembled structures. See sample form for instructions about how to fill out the form correctly.

 Form
 F623-021-000
Application for Insignia for Commercial Coaches

Manufacturer uses this form to apply for an official insignia for commercial coaches that have a plan approval number.

 Form
 F623-019-000
Application for Insignia for Factory Assembled Structures

Manufacturers uses this form to apply for an official insignia for a factory-built structure that has a plan approval number.

 Form
 F623-014-000
Application for LEP Vocational English/Spanish Solicitud para Compensación por Reducción de Ingresos (Vocacional)

Completion of this form is not a guarantee of benefits. Payment of benefits will be decided by your claim manager.

 Form
 F242-209-909
Application for Licensure as an Elevator Mechanic

This is an application for certification as an Elevator Mechanic and is NOT a license to perform work. A contractor''s license is still required by L&I.

 Form
 F621-067-000
Application for Limited Elective Coverage for Licensed Pony Riders

This form is used to provide free-agents the ability to obtain workers’ compensation insurance benefits.

 Form
 F250-026-000
Application for Master Electrician Certification Examination

Use this form to apply for the master electrician exam.

 Form
 F500-088-000
Application for out of State Supplemental Reporting

The purpose of form 212-234-000 -Out of state applications- is to provide a means for an employer to formally request to receive the out-of-state supplemental report for a specific year and state. The form will also allow the department to convey out-of-state reporting requirements and to obtain information needed by the department to set a business up for supplemental reporting.

 Form
 F212-234-000
Application for Pension Benefits by Spouse or Children - (Spanish) Aplicación para Beneficios de Pensión Presentado por el Cónyuge o Hijos

Usado por el cónyuge o dependiente elegido por el trabajador fallecido para recibir un beneficio de sobreviviente.  En el momento en que se determinó que el trabajador estaba permanentemenre y totalmente discapacitado el/ella tomó la decisión de dejar el beneficio de sobreviente al cónyuge o dependiente si el trabajador fallecía.

 Form
 F242-391-999
Application for Pension Benefits by Spouse or Children

Used by a spouse or dependent that was chosen by the deceased worker to receive a survivor benefit. At the time the worker was determined to be totally permanently disabled he/she made a decision to leave a survivor benefit to a spouse or dependent if the worker dies.

 Form
 F242-391-000
Application for Permit to Operate Radio System in Designated Area

This form is used by the logging industry to apply for a permit to operate a radio signal system. What you type in the top form appears in the bottom one, so you have a copy.

 Form
 F416-087-000
Application for Plumber Examination, Reciprocal, Medical Gas Endorsement, or Temporary Permit

This form is used to apply for plumber examination, reciprocal and medical gas endorsement.

 Form
 F627-008-000
Application for Plumber Trainee Certificate

This form is used to apply for a plumber trainee certificate.

 Form
 F627-003-000
Application for Pump Installer Combination General Contractor Registration and Electrical Contractor License

Used for creating combination electrical and plumbing contractors license

 Form
 F500-104-000
Application for Replacement of Lost or Stolen Asbestos Certification Card

This application is for any certified asbestos worker or supervisor that has lost or had their card stolen.

 Form
 F413-068-000
Application for Self-Insurance Certification

Used by employers to apply for self-insurance certification.

 Form
 F207-001-000
Application for Special Certificate to Employ A Vocationally Handicapped Worker at at Subprevailing Wage Rate

Employer Application for Special Certificate to Employ A Vocationally Handicapped Worker at at Subprevailing

 Form
 F700-122-000
Application for Special Certificate to Employ at A Subminimum Wage Rate

Employer Application for Special Certificate to Employ at A Subminimum Wage Rate.

 Form
 F700-120-000
Application for Specialty Electrician Certificate

Application and instructions for the specialty electrician certificate for 03A, 06B, 07A, 07B, 07C, 07D, 07E and 10. Eligibility granted through modified supervision requirements of RCW 19.28.191(1)(g)(ii)

 Form
 F500-098-000
Application for State Plan Insignia for Recreational Vehicles and Recreational Park Trailers

To apply for an insignia for a recreational vehicle.

 Form
 F622-021-000
Application for Telecommunications Contractor''s License

Application used to get an telecommunications contractors license.

 Form
 F503-008-000
Application for LEP Compensation Medical (Spanish) Solicitud para Compensación por Reducción de Ingresos (Médicos)

Completion of this form is not a guarantee of benefits. Payment of benefits will be decided by your claim manager.

 Form
 F242-208-909
Application for Loss of Earning Power (LEP) - Compensation Medical

Completion of this form is not a guarantee of benefits. Payment of benefits will be decided by your claim manager.

 Form
 F242-208-000
Application to Establish an Factory Assembled Structure Deposit Account with the Dept. of Labor and Industries

Use to establish a factory assembled structure (FAS) deposit account. FAS deposit accounts are for businesses or other entities that are not currently licensed or registered with L&I as electrical or construction contractors but are legally required to purchase work permits from L&I. (3 pgs)

 Form
 F120-116-000
Application to Reopen Claim - Spanish Aplicación para Reabrir un Reclamo Debido al Empeoramiento de la Condición

Los beneficios están limitados a $50,000 por reclamo. Si su reclamo ha llegado o excedido  este límite, su solicitud de reapertura será negada y no podremos pagar beneficios futuros.  Usado por las víctimas de crimen y proveedores médicos o de salud mental para solicitar la reapertura de un reclamo.

 Form
 F800-031-999
Application to Reopen Claim due to Worsening Condition - Spanish Aplicación para Reabrir un Reclamo Debido al Empeoramiento de la Condición 

Versión en español.  Usada por los trabajadores lesionados y doctores para solicitar la reapertura de un reclamo de lesión industrial o enfermedad ocupacional que ha estado cerrado por más de 60 días.

 Form
 F242-079-999
Application to Reopen Claim due to Worsening Condition - Spanish APLICACIÓN PARA REABRIR UN RECLAMO

Used by injured workers and doctors to apply to reopen an industrial injury or occupational disease claim that has been closed for longer than 60 days.

 Form
 F242-079-909
Application to Reopen Claim Due to Worsening Condition

This application is by injured workers and providers to apply to reopen an industrial injury or occupational disease claim due to worsening condition for claims that have been claims 60 days or longer.

 Form
 F242-079-000
Application to Reopen Crime Victim Claim Due to Worsening of Condition

Benefits are limited to $50,000 per claim. if your claim has met or exceeded this cap, your reopening application will be denied and we will be unable to pay any further benefits. Used by victims of crime and medical or mental health providers to request a claim be reopened.

 Form
 F800-031-000
Application for Loss of Earning Power (LEP) - Vocational

Completion of this form is not a guarantee of benefits. Payment of benefits will be decided by your claim manager.

 Form
 F242-209-000
Application to Access L&I’s Electronic Permit & Inspection System (EPIS) From Secure Access Washington and Utilize Contractor Deposit Account Via The Internet
 Form
 F621-094-000
Apprenticeship Agreement

Used by the registered apprenticeship program to setup an agreement with the apprentice.

 Form
 F100-016-000
Apprenticeship Committee Representative Qualification Information Experience & Education History

Supplys the experience and education history of new committee members to ensure that they are qualified to be committee members. Used for New Standard submissions only.

 Form
 F100-528-000
Apprenticeship Complaint (Not for Apprenticeship Appeals)

Used to file a complaint on a apprenticeship program, committee, training agent, etc. NOT be used by Apprentices appealing Committee Decisions.

 Form
 F100-505-000
Apprenticeship Related Supplemental Instruction (RSI) Plan Review

Used by apprenticeship programs/sponsors as part of the process of getting new programs/standards/occupations approved.

 Form
 F100-520-000
Apprenticeship Transfer Agreement

Used to allow an apprentice to transfer from a Washington State Registered apprenticeship program to another Washington State Registered program.

 Form
 F100-503-000
Apprenticeships For Tribal Members

 

Brochure: Designed for tribal members, this brochure provides an overview of apprenticeship. Topics include the benefits of apprenticeship, career options, how to apply and contact information.

 

 Publication
 F100-532-000
Approved Training Agent

Used to allow an employer to train apprentices as part of a Registered Apprenticeship program.

 Form
 F100-508-000
Asbestos Abatement Project Notice of Intent and L&I DOSH Asbestos Program

Notice is not required for any asbestos project involving less than forty-eight (48) square feet of surface area, or less than ten (10) linear feet of pipe unless the surface area of the pipe is greater than forty-eight (48) square feet. Get instructions to complete the form.

 Form
 F413-025-000
Assessment Closing Report

Used by only private sector vocational rehabilitation providers to document vocational assessment to determine if a worker is employable based upon transferable skills.

 Form
 F252-029-000
Assessment Eligible Quality Assurance Review Form

For use internally by L&I Vocational Service Specialists (VSSs) to determine if all required components are included in the submitted assessment.  Can be used by VRCs as a tool.  DO NOT SUBMIT TO L&I.

 Form
 F280-008-000
Assignment of Account - WA State Banks Only

Contractors may use this form to request an Assignment of Account in lieu of a surety bond. The amount of the surety bond would need to be placed into an account at a WA State Bank.

 Form
 F625-008-000
Assignment of Account or Time Deposit for Insurance - Bodily Injury - WA State Banks Only

Contractors may use this form to request an Assignment of Account in lieu of an insurance policy for bodily injury. The amount of the insurance policy would need to be placed into an account at a WA State Bank.

 Form
 F625-082-000
Assignment of Account or Time Deposit for Insurance - Property Damage - WA State Banks Only

Contractors may use this form to request an Assignment of Account in lieu of an insurance policy for property damage. The amount of the insurance policy would need to be placed into an account at a WA State Bank.

 Form
 F625-083-000
Attending Doctor''s Handbook

Note: The October 2012 update edition contains limited new information, including a summary of recent workers'' compensation reforms. The inside pages remain the same as the 03-2005 edition. This handbook contains useful information to help providers who treat patients in the workers'' compensation system. Physicians can obtain 3 hours of CE credit by completing an online self-assessment based on this handbook. L&I and the authors have no financial interest or other relationship with the manufacturer(s) of any commercial product(s) and/or provider of commercial services discussed in this document.

 Publication
 F252-004-000
Authorization for Deposit of Payments Spanish Autorización para Depósitos de Pagos (English/Spanish)

Used by pensioner to authorize L&I to deposit the pension payment to any designated financial institution. NOTE: F242-177-999 is the Direct Deposit Letter in Spanish

 Form
 F242-174-909
Authorization for Deposit of Payments

Used by pensioner to authorize L&I to deposit the pension payment to any designated financial institution.

 Form
 F242-174-000
Authorization of Signature

This gives individuals other than the Secretary or Chairman authorization to sign ALL Papers or just Registration Cards. Must be signed by a quorum of the Apprenticeship Committee.

 Form
 F100-500-000
Authorization to Release Claim Information

Used by the worker to designate a person(s) as an authorized representative for the worker''s claim. An authorized representative can access claim information.

 Form
 F101-010-000
Autorización para Proveer Información de Reclamos

Usado por el trabajador para designar a una persona(s) como representante(s) autorizado(s) del reclamo del trabajador.  Un representante autorizado puede obtener acceso a la información de reclamo.

 Form
 F101-010-999
Autorization del Trabajador para Obtener Registros de Trabajos Despachados por el Sindicato

Autorización del trabajador para obtener registros de trabajos despachados por el sindicato.

 Form
 F242-410-999
Avoid Liability for Your Farm Labor Contractor''s Unpaid Debits (English/Spanish) / Evite su Obligación por las Deudas no Pagadas de su Contratista de Trabajadores Agrícolas

Fact sheet: Explains how employers could be liable for unpaid workers'' compensation premiums, unpaid wages, damages and civil penalties when hiring a farm labor contractor. Outlines ways to protect against potential liability.

 Publication
 F700-154-909
Ayuda para Trabajadores Lesionados de Empresas Autoaseguradas

Tarjeta de información:  Hace una introducción de la Oficina del (Defensor) Ombudsman para trabajadores lesionados autoasegurados.  El defensor es nombrado por el Governador para servir como un defensor independiente de los derechos de los trabajadores lesionados de empleadores autoasegurados.

 Publication
 F207-201-999
Ayuda para Víctimas de Crimen (cartel grande)

Cartel (11" X 17"): Resalta el Programa de Compensación para Víctimas de Crimen y proporciona información para comunicarse con el programa. La intención es ponerlo a la vista en clínicas, organizaciones judiciales y de servicios sociales. Puede descargarse e imprirse o solicitarse de L&I.  Hay una versión más pequeña (8.5" X 11") disponible.

 Poster
 F800-041-999
Ayuda para Víctimas de Crimen (cartel)

Cartel (8.5" X 11"): Resalta el Programa de Compensación para Víctimas de Crimen y proporciona información para comunicarse con el programa. La intención es ponerlo a la vista en clínicas, organizaciones judiciales y de servicios sociales.  Puede descargarse e imprirse o solicitarse de L&I. Hay una versión más grande (11" X 17") disponible.

 Poster
 F800-104-999
Beneficios de Compensación para los Trabajadores: Una guía para los Trabajadores Lesionados

Folleto: Explica los derechos y responsabilidades de los trabajadores bajo la ley de seguro industrial.  Describe beneficios y cómo presentar un reclamo.  Aviso: Anteriormente titulado, Guía de Beneficios del Seguro Industrial para los Trabajadores.  

 Publication
 F242-104-999
Billing Guidelines for Sexual Assault Examinations: Crime Victims Compensation Program

Provides information health-care providers need to bill the Crime Victims Compensation Program for medical services.

 Manual
 F800-100-000
Borrower Agreement Form Safety and Health Video Library

Borrower Agreement Form - To open an account and borrow videos, please fill out this form.

 Form
 F417-205-000
Bulk Cargo Spouts, Suckers, and Similar Equipment for Maritime Operations

Bulk Cargo Spouts, Suckers, and Similar Equipment for Maritime Operations

 Form
 F416-052-000
Business and Industry Category Guide

Manual: Provides assistance to retro groups in determining if a prospective employer qualifies for their retrospective rating group program.

 Manual
 F250-025-000
Cómo calcular su salario en agricultura

Hoja de información: Muestra a los trabajadores por contrato como calcular sus salarios y verificar si le están pagando salario mínimo.

 Publication
 F700-171-999
Cómo Hacer la Mejor Elección de Tratamiento para el Dolor Crónico en la Parte Inferior de su Espalda

Hoja de información:  Revisa las opciones que un trabajador lesionado con dolor en la parte inferior de la espalda debe considerar para determinar la elección del mejor tratamiento.

 Publication
 F252-081-999
Cómo Registrar un Reclamo para la Compensación del Trabajador con Empresas Autoaseguradas

Usado solamente por los empleadores autoasegurados para cumplir con el Código Administrativo de Washington (WAC, por su sigla en inglés) 296-15-400.  El formulario proporciona información e instrucciones para los empleados de empleadores autoasegurados en caso de una lesión o desarrollo de una enfermedad ocupacional.

 Form
 F207-155-999
Cancellation of Elective Coverage - Sole Proprietors/Partner, Member of Limited Liability Company (LLC), Member of Limited Liability Partnership (LLP) or For-Profit Corporate Officers

Used by an employer to cancel workers'' compensation coverage for Sole Proprietors/Partner, Member of Limited Liability Company (LLC), Member of Limited Liability Partnership (LLP) or For-Profit Corporate Officers.

 Form
 F213-004-000
Cancellation of Elective Coverage for Excluded Employments

Used by employers to get the categories of employment that are not considered mandatory to have workers'' compensation. If they had elected to have coverage this form is used to cancel previously elected coverage of workers'' compensation.

 Form
 F213-005-000
Casas prefabricadas y móviles: Lo que los dueños de casas y contratistas deben saber al modificar una vivienda

Panfleto/folleto: Cubre asuntos que usted debe considerar al modificar su casa. Define lo que significa modificación, reparación y sustitución e incluye consejos para contratar contratistas registrados. También incluye información de comunicación para el Programa de L&I para asistencia al consumidor para dueños de casas prefabricadas /móviles.

 Publication
 F622-049-999
Caution: Hard Hat Area / Precaución: Obligatorio Usar Casco (English/Spanish)

Picture of hard hats. Get poster printing tips.

Fotografía de cascos.  Obtenga información sobre cómo imprimir carteles.

 Poster
 FSP0-928-999
Certificado de Cobertura - Ejemplo

Ejemplo que muestra una copia del Certificado de cobertura.  Usted debe solicitar el formulario, no puede descargarlo de la Internet.

 Form
 F211-141-999
Certificate of Coverage - SAMPLE ONLY

Sample of what the Certificate of Coverage looks like. You must order the form, you cannot download it off the internet.

 Form
 F211-141-000
Certified Project Payroll

There are instructions in one PDF file, and a blank form that may be printed in the other PDF. The word document is saved in Microsoft 2003 format and is a fillable word form.

 Form
 F700-065-000
Challenges and Change: Managing and Innovating through The Great Recession — L&I from 2005-2012

Booklet: Discusses the impact of the Great Recession on L&I’s programs and highlights accomplishments from 2005 to 2012.

 Publication
 F101-102-000
Change Assignment of Administrator/Master Certificate

To assign or unassign your status as an administrator or master.

 Form
 F503-009-000
Change Assignment of Primary Point of Contact

Change Assignment of Primary Point of Contact

 Form
 F621-095-000
Chapter 19.28 RCW - Electricians and Electrical Installations

Simplified version of the Chapter 19.28 RCW - Electricians and Electrical Installations Rules

 Manual
 F500-039-111
Chapter 296-131 WAC Agriculture Employment Standard
 Form
 F700-085-000
Chapter 296-807 WAC - Portable Power Tools

Portable power tools applies to hand-held power tools; circular saws, belt sanding machines, compressed air powered tools, powder actuated fastening systems designed to use the expanding gases from a powder load to propel a stud, pin, fastener, or other object into hard structural material, consumer and commercial power lawnmowers, portable hand- or power-operated hydraulic, mechanical ratchet and mechanical screw jacks.

 Manual
 F414-089-000
Charter Vessel Inspection

Form used for the applicant to complete a Certification of Inspection of a charter boat.

 Form
 F416-058-000
Chemical Exposure Questionnaire Packet

Packet that contains:

F242-409-000 Chemical Exposure Questionnaire

F242-410-000 Worker Release for Union Dispatch Records

F262-005-000 Authorization to Release Information

Request for Social Security Earnings Information with the L&I address.

 Form
 F242-409-000
Cholinesterase Blood Testing Choice

Use this form to say whether or not you choose to have the Cholinesterase blood tests performed.

 Form
 F413-064-000
Cholinesterase Monitoring Health Care Provider Recommendations

Filled out by the provider. This form gives the recommendations by the provider of what needs to be done based on the test results on the employee.

 Form
 F413-070-000
Cholinesterase Monitoring Reimbursement Request

Employers use this form to request reimbursement for the reasonable costs of training, travel, recordkeeping, and medical expenses for Cholinesterase Monitoring.

 Form
 F413-062-000
Chronic Opioid Request Form

Use this form to request opioid coverage beyond 12 weeks from the date of injury or surgery, or every 90 days for chronic opioid therapy.

 Form
 F252-091-000
Claim for Pension by Spouse or Children -  Reclamo para Beneficios de Pensión Presentado por el Cónyuge, Pareja Doméstica Registrada o los Hijos (Spanish)

Usado por el cónyuge o dependientes de un trabajador fallecido. EL accidente fatal o enfermedad ocupacional del trabajador que ocurrió en el transcurso del empleo.  Esta solicitud es necesaria para determinar si el(los) solicitante(s) tienen derecho a recibir beneficio de sobreviviente.

 Form
 F242-056-999
Claim Suppression Complaint

An injured worker may submit this form if their employer has suppressed their right to file an injury claim.

 Form
 F262-024-000
Class B Labels: What You Should Know

Fact Sheet: Explains Class B label electrical work, scope and limitations, and provides general instructions for using Class B labels.

 Publication
 F500-112-000
Comentarios Sobre el Exámen Médico Independente

Usado por el trabajador lesionado para proporcionarle comentarios a L&I sobre su examen médico reciente de un Examen Médico Independiente (IME, por su sigla en inglés).

 Form
 F245-053-999
Commercial Diving Operations, Chapter 296-37 WAC

This manual contains basic safety and health rules that affect all employers and should cover almost all commercial diving operations. This manual also covers search and rescue and other public safety diving operations.

 Manual
 F414-039-000
Competent Person Evaluation - Excavation & Trenching

The employer uses this checklist to determine the person they have designated as a competent person is competent within the description and intent of the excavation and trenching standards.

 Form
 F417-104-000
Competent Person Evaluation - Fall Restraint & Fall Arrest

The employer uses this checklist to determine the person they have designated as a competent person is competent within the description and intent of the fall restraint and fall arrest standard.

 Form
 F417-102-000
Complete Stay at Work Guide for Employers, The

Booklet: Explains Stay at Work, a financial incentive program that encourages Washington employers to find light-duty or transitional jobs for workers recovering from on-the-job injuries. Provides information on reimbursements, what is covered and how to apply. Detailed Q&A section included.

 Publication
 F243-005-000
Construction Checklist - Safety - Spanish - Lista de Verificación de Seguridad en la Construcción

Construction Checklist - Safety - Spanish - Lista de verificación de seguridad en la construcción

 Form
 F418-055-999
Construction Checklist - Safety

Construction Checklist - Safety

 Form
 F418-055-000
Construction Contractor''s Application for Workers'' Compensation Account with No Workers or Hours

Used by employers with no employees or worker hours to report but need an open account for contract bidding process.

 Form
 F625-077-000
Construction Contractors: Get the Facts, Get Registered

Pamphlet/booklet: Explains the steps to register as a construction contractor in Washington State.

 Publication
 F625-040-000
Construction Elevator Installation Application and Inspection Data Report

Used by companies to apply for an Construction Elevator (Hoist) at a job site. One application per car and companies need to contact the Elevator Section for the appropriate installation and operating fee.

Allow two weeks for a response. Accuracy and completeness speeds up the processing time.

 Form
 F621-001-000
Construction Industry Classification Guide

Book (loose-leaf manual): Helps contractors properly classify for workers'' compensation insurance purposes the work being performed by their employees on new wood-frame building construction projects.

 Publication
 F213-008-000
Construction Lien Notice

This form is to be used by suppliers to notify homeowners that they have the ability to file a construction lien against their property if payment is not received.

 Form
 F625-054-000
Continuación del Historial de Trabajo y de Enfermedad Ocupacional

El trabajador lesionado llena este formulario para documentar una posible enfermedad ocupacional y para mostrar su historia de trabajo.

 Form
 F242-071-911
Continuous Contractor''s Surety Bond

This form is used for the surety bond for construction contractors and is required by the Contractor''s Registration Act (RCW 18.27). The bond must be produced by a bonding company.

 Form
 F625-003-000
Contract: Report By Contractor - Forest, Range & Timber Industry

This report by the contractor needs to be completed and sent before any contractural agreement with a forest, range and/or timber industry landowner can start any work covered by this agreement.

 Form
 F213-011-000
Contract: Report By Landowner - Forest, Range & Timber Industry

The landowner needs to complete and submit this form before any contractural agreement with a forest, range and/or timber industry contractor can start any work that is covered by this agreement.

 Form
 F213-010-000
Contractor Complaint Form

Used by a home owner to file a complaint against a contractor.

 Form
 F625-033-000
Contractor Electrical Work Permit Application

This application is used to apply for a valid electrical permit from L&I. 4 pages.

 Form
 F500-093-000
Contractor Financial Information

Used by the contractor to request L&I to release assignment of account that they used instead of a surety bond.

 Form
 F625-061-000
Contractor Registration Officers/Members Addendum

Contractor Registration Officers/Members Addendum

 Form
 F625-109-000
Contractor Registration Request for Duplicate License or Address Change  

This form may be faxed to the Contractor Registration office in Tumwater.

 Form
 F625-108-000
Contractors: What if You Get a Notice of Infraction?

Pamphlet/booklet: Tells contractors what their options are and what to do if they get a Notice of Infraction (a non-criminal violation). This publication currently unavailable due to revisions in progress. Check back for updates.

 Publication
 F625-097-000
Contratistas de Construcción: Obtenga los Datos, Regístrese

Panfleto/folleto: Explica los pasos para registrarse como contratista de construcción en el estado de Washington.

 Publication
 F625-040-999
Convenio para el Tratamiento con Opioides

Utilice este convenio de tratamiento al iniciar la terapia con opioides para controlar el dolor crónico.  El convenio debe ser renovado cada año o cuando hay un proveedor nuevo proporcionándole recetas.

 Form
 F252-095-999
Conveyance Installation Approval by Building Official

Used by the installer to notify L&I that a conveyance is proposed for installation in a building.

 Form
 F621-056-000
Copper Tubing Gas Line Pre-Inspection Checklist

This checklist is used by the contractor when installing gas lines with copper tubing. Be sure you can answer YES to all questions before calling L&I for an inspection.

 Form
 F622-046-000
Court Form Granting Permission for Employment of Minors

Form from Court Granting Permission for Employment of Minors to the employer.

 Form
 F700-119-000
Coverage Agreement

An agreement between a worker and employer which states the worker''s employment is principally localized in Washington state or another state.

 Form
 F212-044-000
Cranes, Derricks and Material Handling Devices Worksheet for Maritime Industry

Use this form for the inspection of cranes, derricks and materials handling devices on waterfront operations

 Form
 F416-051-000
Crew Leader Safety Meeting

Use this form to document the minutes of your safety meetings.

 Form
 F417-049-000
Crime Victim Compensation Program Sexual Assault Exam Report

A form used by physicians, hospitals and clinics to provide information and reporting to the Crime Victims Compensation Program.

 Form
 F800-098-000
Crime Victim Worker Verification - Spanish - Formulario de Verificación de Empleo

Crime Victim Worker Verification - Spanish - Formulario de Verificación de Empleo

 Form
 F800-110-999
Crime Victims Address Change Request

Crime Victims Address Change Request

 Form
 F800-112-000
Crime Victims Compensation Program Initial Response and Assessment: Form II

Used by the clinical provider to request authorization to provide more than six sessions. This form must be submitted by the sixth session. (6 pages)

 Form
 F800-081-000
Crime Victims Compensation Program Progress Note: Form III

Used by the clinical provider to submit a request for preauthorization for payment of additional sessions.

 Form
 F800-082-000
Crime Victims Compensation Program Termination Report: Form VI

Used by the clinical provider to inform L&I that you are no longer conducting treatment to the client. This must be submitted within 60 days of the client''s last session and you are no longer conducting treatment.

 Form
 F800-085-000
Crime Victims Compensation Program Treatment Report: Form IV

Used by the clinical provider to request preauthorization for payment of additional sessions.

 Form
 F800-083-000
Crime Victims Compensation Program Treatment Report: Form V

Used by the clinical provider to get preauthorization for payment of additional sessions.

 Form
 F800-084-000
Crime Victims Statement for Home Nursing Services

Used by the Crime Victims Compensation Program providers for reimbursement of home nursing services. Crime Victims Compensation Program providers are required to bill using this form.

 Form
 F800-070-000
Crime Victims Statement for Pharmacy Services

Used by Crime Victims Compensation Program providers to bill for pharmacy services. Crime Victims Compensation Program providers are required to bill using this form.

 Form
 F800-058-000
Crime Victims Provider''s Request for Adjustment

Used by providers to request an adjustment to their bill if their entire bill was paid in error, or if a portion of the bill was overpaid or underpaid. Attach required reports and/or documentation to support the request.

 Form
 F800-064-000
Crime Victims'' Statement for Compound Prescription

Bill form for use by pharmacies and home infusion companies to submit compound drug charges for Crime Victims Compensation. This form is for drug charges only and is filled out by the pharmacist.

 Form
 F800-067-000
Cuando un ser querido fallece en el lugar de trabajo

Folleto: Proporciona información para los seres queridos de trabajadores que mueren de una lesión o enfermedad relacionada con el trabajo, incluyendo cómo solicitar beneficios de sobreviviente. Explica la investigación de L&I por una muerte y cómo los miembros de la familia pueden mantenerse informados sobre el estado de la investigación.

 Publication
 F417-240-999
Cuestionario de Exposición a Sustancias Químicas

El formulario contiene el  Cuestionario de exposición a sustancias químicas F242-409-999, la Autorización para proveer información  F262-005-999 y la versión en inglés solamente de un formulario del Seguro Social que contiene la información apropiada de L&I.

 Form
 F242-409-999
Cuestionario Sobre la Pérdida del Sentido Auditivo en el Trabajo

Usada por el trabajador lesionado que ha presentado un reclamo por pérdida de audición para proporcionar información más específica referente a cómo ocurrió la pérdida de audición.  Esto es solicitado por el Gerente de reclamo y enviado al trabajador lesionado.

 Form
 F262-016-999
CVCP Opioid Progress Report Chronic, Non-Cancer Pain and Treatment Agreement.

Crime Victims Compensation Opioid Progress Report Chronic, Non-Cancer Pain and Treatment Agreement.

 Form
 F800-116-000
Danger / Cartel - PELIGRO (English/Spanish)

Large lettering: DANGER. Get poster printing tips.

En letras grandes: PELIGRO

 Poster
 FSP1-030-999
Danger! Minimum Clearance for Counter Balance - Construction

Sticker: 30 inches long.

 Sticker
 FSP0-974-000
Danger! Minimum Clearance for Counter Balance - Logging
 Sticker
 FSP0-972-000
Danger, Workers Above / Peligro - Trabajadores en el Nivel Superior (English/Spanish)

Picture of workers on a high rise. Get poster printing tips.

Fotografía de unos trabajadores en una superficie alta.  Obtenga instrucciones sobre cómo imprimir los carteles.

 Poster
 FSP1-012-999
Decertification of Manufactured and Mobile Homes

This document shows the steps to decertify a manufactured or mobile home.

 Form
 F622-063-000
Declaración de Derechos para Dependiente del Trabajador Fallecido Bajo el Programa de Compensación y Beneficios para Trabajadores

Usado por un dependiente de un trabajador cuya muerte estaba relacionada con una lesión o accidente en el trabajo.  Este formulario debe completarse, firmarse, notariarse y devolverse a L&I dentro de 30 días para que los beneficios no sean interrumpidos.

 Form
 F242-173-933
Declaración de Derechos para Padres o Tutor Bajo el Programa de Compensación y Beneficios para Trabajadores

Usado por un tutor u otra persona que tiene custodia del hijo menor o discapacitado o dependientes de un trabajador fallecido para declarar su  derecho a recibir los beneficios de pensión para aquellos niños/dependientes bajo su cuidado y custodia.

 Form
 F242-173-922
Declaración de Derechos para Viuda(o) bajo el Programa de Compensación y Beneficios para Trabajadores

Usado por una viuda/viudo cuyo cónyuge falleció a causa de una lesión o accidente relacionado con el trabajo.  Este formulario debe completarse, firmarse, notariarse y devolverse a L&I dentro de 30 días para que los beneficios no sean interrumpidos.

 Form
 F242-173-911
Declaración de Derechos para los Beneficios de un Trabajador Totalmente Discapacitado Bajo las Leyes del Seguro Industrial

Usado por un trabajador permanentemente y totalmente discapacitado.  Este formulario debe completarse, firmarse, notariarse y devolverse a L&I dentro de 30 días para que los beneficios no sean interrumpidos.

 Form
 F242-173-944
Declaración de Servicios de Capacitación y Modificación de Trabajo

Formulario de cobro para proveedores que facturan al Departamento por capacitación y servicios de modificación de trabajo.

 Form
 F245-030-999
Declaración para Servicios Misceláneos

Este formulario es utilizado por proveedores y trabajadores lesionados para cobrarle al Departamento por servicios tales como, cuidado dental; lentes; cuidado de enfermería en el hogar; equipo médico, servicios de intérprete; servicios que los trabajadores pagan por su cuenta y otros servicios.

 Form
 F245-072-999
Demounting and Mounting Procedures for Tube-type Truck and Bus Tires

Poster for tire and rim servicing. To be displayed with F417-237-000-A Demounting and Mounting Procedures for Tubeless Truck and Bus Tires and F417-237-000-C Multi-piece Rim Matching Chart. This poster must be printed at least 2''x3'' in size.

 Poster
 F417-237-000-B
Demounting and Mounting Procedures for Tubeless Truck and Bus Tires

Poster for tire and rim servicing. To be displayed with F417-237-000-B Demounting and Mounting Procedures for Tube-type Truck and Bus Tires and F417-237-000-C Multi-piece Rim Matching Chart. This poster must be printed at least 2''x3'' in size.

 Poster
 F417-237-000-A
Department of Employment Security Tax Compliance Certification

Form to gain Department of Employment Security Tax Compliance Certification for registered Farm Labor Contractors.

 Form
 F700-099-000
Department of Labor and Industries Home Modification Acknowledgement of Responsibilities

Used by both workers and bidding contractors to read, sign and submit to L&I to verify that they have read, understand and accept their respective responsibilities in the home modification process.

 Form
 F247-003-000
Department of Revenue Tax Compliance Certification

Form to gain Department of Revenue Tax Compliance Certification for registered Farm Labor Contractors.

 Form
 F700-100-000
Discriminación de seguridad y salud en el lugar de trabajo

Folleto: Los empleados tienen derecho a reportar sus inquietudes sobre seguridad y salud en sus lugares de trabajo.  Este folleto describe las “actividades protegidas": bajo la Ley de Seguridad y Salud Industrial de Washington (WISHA, por su sigla en inglés) y explica lo que debe hacer un empleado si él/ella es castigado o despedido por ejercer estos derechos.

 Publication
 F417-244-999
Drywall Contractors

Quick reference guide: Used by drywall contractors to get answers to questions about being a drywall contractor and how it relates to L&I.

 Form
 F214-024-000
Drywall Industry - Owner/Sub-Contractor Report

Used by drywall companies to file their quarterly report. Must accompany the Supplemental Quarterly Report for the Drywall Industry (F212-051-000).

 Form
 F212-050-000
Elección para Prueba de Sangre de Colinesterasa

Use este formulario para indicar si usted elije o no que se le hagan examenes de Colinesterasa en la sangre.

 Form
 F413-064-999
Electric / Gas Conversion Pre-Inspection Checklist

This checklist is generic in content and may not include all requirements for your particular installation. The manufacturer''s installation instruction must be adhered to and available to the inspector at the time of the inspection.

 Form
 F622-013-000
Electrical / Telecommunication Contractor''s License Renewal Notice

This form is used to notify you that your license will expire and for you to use to renew your license.

 Form
 F500-077-000
Electrical Continuing Education Instructor Application

An application to receive approval from L&I to instruct electrical continuing education courses.

 Form
 F500-090-000
Electrical Education Course Application

Used to get approval of a course as an electrical continuing education class. This application must be received by L&I at least 30 days before the course is offered.

 Form
 F500-068-000
Electrical Installation Variance Application

To apply for a variance which is an allowable deviation from specific requirements of a National Electrical Code section, or the WAC 296-46B where the proposed alternate methods will maintain equivalent safety.

 Form
 F500-063-000
Electrical Program Contacts

Fact Sheet: Provides information for requesting electrical inspections, including telephone numbers and locations of L&I offices that handle electrical inspections.

 Publication
 F500-114-000
Electrical Safety Standards,Administration, and Installation WAC 296-46B

Electrical Safety Standards,Administration, and Installation WAC 296-46B

 Manual
 F500-039-222
Electrical Telecommunication Principal Member Owner Update Request

Electrical Telecommunication Principal Member Owner Update Request

 Form
 F500-124-000
Electrical/Telecommunications Contractor Assignment of Savings Account

This is used to assign ownership interest to a savings account that is held by L&I for one year after a contractor''s license has expired or after the contractor ceases business in Washington State.

 Form
 F500-020-000
Electrical/Telecommunications Contractor''s Bond to the State of WA

Used to show proof of a bond in the State of Washington.

 Form
 F500-019-000
Electronic Billing Authorization

To authorize L&I to accept electronically submitted bills for services provided to injured workers (2 pages).

 Form
 F248-031-000
ELEVATOR ACCOUNT DEPOSIT FOR CONTRACTOR’S OR MISCELLANEOUS ACCOUNT HOLDER’S

ELEVATOR ACCOUNT DEPOSIT FOR CONTRACTOR’S OR MISCELLANEOUS ACCOUNT HOLDER’S

 Form
 F621-098-000
Elevator Continuing Education Course Application

This is used to apply for approval of elevator related continuing education courses.

 Form
 F621-077-000
Elevator Continuing Education Instructor Application

Application to become an instructor for elevator related courses.

 Form
 F621-078-000
Elevator Five-Year Safety Test Report

This report is used by elevator company mechanics and left on the job site for review by elevator inspectors.

 Form
 F621-051-000
Elevator Information Update

This form is required by L&I before they can process any changes to the ownership, physical or mailing address.

 Form
 F621-050-000
Elevator Installation Variance Application

Property owner or elevator company can apply for a variance to install an elevator. 4 pages.

Allow 4-6 weeks for a response.  Accuracy and completeness speeds up the processing time.

 Form
 F621-048-000
Elevator Mechanic and Elevator Temporary Mechanic Address/Mailing Information Update

Elevator Mechanic and Elevator Temporary Mechanic Address/Mailing Information Update

 Form
 F621-100-000
Employer Petition to The Court for Minor Work Permit Under Age 14

Petition to The Court for Minor Work Permit Under Age 14 by Employer.

 Form
 F700-118-000
Employer Rights - Wages Paid

Covers penalties for employer wage violations. Once stock runs out in warehouse, this form will be internet only.

 Form
 F700-058-000
Employer''s Guide to the Hazard Communication Rule (Chinese)

Booklet: Washington State''s new Hazard Communication rule became effective April 15, 2013. It is intended to improve understanding of hazard information found on product labels. The booklet includes training requirements, a Q&A about who is covered, pictograms, descriptions of hazards and everything employers need to know and do to be in compliance.

The changes are based on the International Globally Harmonized System of Classification and Labeling of Chemicals (GHS).

 Publication
 F413-012-888
Employer''s Guide to the Hazard Communication Rule (Korean)

Booklet: Washington State''s new Hazard Communication rule became effective April 15, 2013. It is intended to improve understanding of hazard information found on product labels. The booklet includes training requirements, a Q&A about who is covered, pictograms, descriptions of hazards and everything employers need to know and do to be in compliance.

The changes are based on the International Globally Harmonized System of Classification and Labeling of Chemicals (GHS).

 Publication
 F413-012-777
Employer''s Job Description

Used by employer of record to prepare a written job description for a light-duty job, transitional, modified duty job, or alternative job when an injured worker is unable to work due to an industrial injury or occupational disease. The form includes a description of the job tasks, machinery, tools, equipment and personal protective equipment used, and the physical demands of the job. After completing the employer''s job description form, the employer gives it to the injured worker''s doctor for review and approval.

 Form
 F252-040-000
Employers’ Guide to Workers’ Compensation Insurance in Washington State

Book: Explains the Washington State''s workers'' compensation program. Suggests ways to protect workers'' safety and health and describes L&I programs to help employers control premium costs.

 Publication
 F101-002-000
Employing Children Under Age 14 in Non-Agricultural Jobs

Fact sheet: Explains when employers can and cannot employ minors under age 14 in non-agricultural jobs. Details the process for obtaining court permission when hiring minors under 14 is allowed.

 Publication
 F700-117-000
Employing teens under 18 in food service? - L&I’s fact sheet of permitted and prohibited work activities for youth ages 14 to 17 in food service

Fact sheet: Explains permitted and prohibited work activities for youth ages 14 to 17 in food service. Includes rules for driving, student-learner exemptions and work hours.

 Publication
 F700-167-000
Employment History Form Spanish Formulario de Historial de Empleo

Usado por el trabajador lesionado para reportar su historial de empleo y el salario de cada trabajo durante los últimos tres años

 Form
 F242-109-999
Employment History Form

Used to provide your employment history for the past three years, including self-employment and volunteer work.

Please start with your most recent job and work backwards. Please list any gaps or interruptions in your work history.  If you were unemployed at any time, please explain why.  Did you apply for (or receive) unemployment benefits during the time period? If yes, what dates did you receive unemployment benefits?  Did you seek employment during the time period?  If no, why didn’t you seek employment?

 Form
 F242-109-000
Encursta para la Evaluacion de los Daños

Sus respuestas a estas preguntas serán utilizadas para ayudar a evaluar sus daños si se presenta un reclamo indicando que un tercero es responsable por los daños.

 Form
 F242-067-999
Equal Employment Opportunity (EEO) Resource & Referral Update Form

Used by an organization to get on the Apprenticeship Program equal opportunity resources list or use to update their information on the list.

 Form
 F100-513-000
Evaluando su Capacidad para Trabajar: Sus Derechos y Responsabilidades, Servicios de Rehabilitación Vocacional

Folleto: Explica lo básico de la etapa de evaluación de los servicios vocacionales para los trabajadores lesionados. L&I le envia este folleto a los trabajadores lesionados cuando son referidos para servicios de evaluación.

 Publication
 F280-017-999
Evaluating Retro Groups

Fact sheet: Provides information to employers who are considering joining a Retrospective Rating (Retro) group and how to choose one that best fits the need of their company. Explains the process for enrollment, deadlines, group eligibility, assessment, distribution of funds, dues, fees, services, and exit clauses.

 Publication
 F225-019-000
Extension Request

This form is to request a time extension from an unforeseen circumstances for overdue corrections for conveyances.

 Form
 F621-053-000
F242-208-999 Application for LEP compensation medical - Spanish Solicitud para Compensación por Reducción de Ingresos (Médico)

Completion of this form is not a guarantee of benefits. Payment of benefits will be decided by your claim manager.

 Form
 F242-208-999
F242-209-999 application for LEP - Voc Spanish -  Aplicación para Compensación por Reducción de Ingresos (Vocacional)

Completando este formulario no es una garantía para recibir beneficios.  El pago de beneficios lo decidirá su gerente de reclamo.

 Form
 F242-209-999
Factory Assembled Structures Alteration Application

Used by a homeowner or contactor to request a field inspection for an alteration to a manufactured or mobile home.

Allow 1-2 days for a response to alteration applications for Manufactured/Mobile Homes.

All other alteration applications, allow 2-3 weeks for a response. Accuracy and completeness speeds up the processing time.

 Form
 F622-036-000
Fall Protection Work Plan Requirements

This booklet defines the work plan requirements you must meet for fall protection.

 Form
 F417-107-000
Fall Protection Work Plan Requirements

This booklet defines the work plan requirements you must meet for fall protection.

 Publication
 F417-107-000
Farm Internship Agreement

Agreement form: Prior to hiring an intern, farms that have received a Farm Intern Program certificate must complete this agreement with the intern and submit it to the department.

 Form
 F700-157-000
Farm Internship Project Complaint Form

Complaint form for public to complete and submit

 Form
 F700-172-000
Farm Labor Contractor Application/Renewal Packet

This is the packet you would complete to register as a farm labor contractor.

 Form
 F700-170-000
Farm Labor Contractor Assignment of Account or Time Deposit

Farm Labor Contractor assignment of account or tme deposit for employee

 Form
 F700-060-000
Farm Labor Contractor Checklist

Farm Labor Contractor''s Checklist to ensure compliance.

 Form
 F700-112-000
Farm Labor Contractor Complaint Form

Used to file a complaint against a Farm Labor Contractor, landowner, employer, or other where a possible infraction is concerned.

 Form
 F700-109-000
Farm Labor Contractor Registration

Fact Sheet: Explains how to get a farm labor contractor license in order to operate legally as a farm labor contractor in Washington State.

 Publication
 F700-088-000
Farm Labor Contractor Registration

Hoja de datos:  Explica cómo obtener una licencia de contratista agrícola para poder operar legalmente como un contratista agrícola en el estado de Washington.

 Publication
 F700-088-999
Farm Labor Contractors Bond

Notarized farm labor contractors bond coverage.

 Form
 F700-066-000
Filing Suit Against an Electrical Contractor

Instructions for filing suit against an electrical contractor

 Form
 F625-053-000
Financial Statement Businesses

Requesting Financial Information for Corporations, LLC and Partnerships.

 Form
 F215-040-000
Financial Statement Sole Proprietors and Individuals

Requesting Financial Information for Sole Proprietors and/or Individuals.

 Form
 F215-039-000
Firm Vocational Provider Account Change

To change a firm''s (payee provider''s) branch address within the same service location, contact info, tax info, adding or deleting designee for your firm.

 Form
 F252-022-000
First Aid

Safety Sticker size 5"x6"

 Sticker
 FSP1-005-000
Flood Damaged Manufactured Home Checklist

Checklist on how to repair a flood damaged manufactured home. After the contractor has done all that is required by the checklist they call L&I for an inspection.

 Form
 F622-040-000
Forklift Safety: Training requirements and helpful tips

Fact sheet: Provides answers to the most-often asked questions about forklift training. Includes a checklist that employer may use to document that employees have been trained and/or evaluated in the required topics.

 Publication
 F417-202-000
Formulario de Queja en Contra de un Contratista de Trabajores Agrícolas (Farm Labor Contractor Complaint)

Usado para presentar una queja contra un contratista agrícola,  hacendado, empleador u otro en lo que se refiere a una infracción.

 Form
 F700-109-999
Formulario de Queja sobre los Derechos Laborales

Formulario de queja sobre los derechos laborales.  Las versiones de octubre de 2010 y de diciembre 2011 son válidas.

 Form
 F700-148-999
Gas Piping Test Affidavit

You fill out, print and make a copy of this form on your company''s letterhead. This affidavit must be available for the L&I inspector when the inspection is made.

 Form
 F622-048-000
Gas Room Heaters Pre-Inspection Checklist

This checklist is used by the contractor when installing gas room heaters. Be sure you can answer YES to all questions before calling L&I for an inspection.

 Form
 F622-045-000
General Provider Billing Manual

General billing information for those providers that bill the department.

 Manual
 F248-100-000
Grinding Wheel - Prevent Accidents

Sticker size 4"x3"

 Sticker
 FSP1-000-000
Guía de Beneficios de Compensación para los Trabajadores: Para los Empleados de Empresas Autoaseguradas

Pamfleto/folleto: Explica a los empleados de negocios autoasegurados sus derechos y responsabilidades bajo la ley de seguro industrial.  Describe los beneficios y como  presentar un reclamo.

 Publication
 F207-085-999
Guía para el Contratista Independiente - Una guía detallada para contratar contratistas independientes en el estado de Washington

Panfleto/Folleto: Una guía detallada para contratar contratistas independientes en el estado de Washington.  Esta publicación es una guía general para ayudarlo a entender cómo y cuándo el Departamento de Labor e Industrias aplica las leyes de compensación para los trabajadores a los contratistas independientes.

 Publication
 F101-063-999
Guía Sobre La Norma de Comunicación de Riesgos Químicos

Booklet: Washington State''s new Hazard Communication rule became effective April 15, 2013. It is intended to improve understanding of hazard information found on product labels. The booklet includes training requirements, a Q&A about who is covered, pictograms, descriptions of hazards and everything employers need to know and do to be in compliance.

The changes are based on the International Globally Harmonized System of Classification and Labeling of Chemicals (GHS).

 Publication
 F413-012-999
Guide to the Hazard Communication Rule (Vietnamese)

Booklet: Washington State''s new Hazard Communication rule became effective April 15, 2013. It is intended to improve understanding of hazard information found on product labels. The booklet includes training requirements, a Q&A about who is covered, pictograms, descriptions of hazards and everything employers need to know and do to be in compliance.

The changes are based on the International Globally Harmonized System of Classification and Labeling of Chemicals (GHS).

 Publication
 F413-012-555
HB 2253 Open Window Opportunity - Affidavit of Hours of Unsupervised Telecommunications Installation Experience

This form is not available until June 12.

 Form
 F500-127-000
Hearing Aid Repair Authorization Fax Request

Hearing Aid Repair Authorization Requests. If you need to purchase or replace a hearing aid, fax all of the information required by Medical Aid Rules and Fee Schedule (MARFS) including the Hearing Services Worker Information (F245-049-000) to 360-902-6252.

 Form
 F245-384-000
Hearing Services Worker Information

This is a list of the rights and conditions when an injured worker applies for hearing aids.

 Form
 F245-049-000
Heat-related Illness Education Card/Tarjeta de Educación sobre Enfermedades Relacionadas con el Calor (English/Spanish)

Identifies the effects of heat exhaustion and heat stroke on the body and what to do if you observe symptoms. Reviews prevention steps. PDF file is set up for two copies to print at one time.

 Publication
 F417-218-909
Help for Crime Victims (large poster)

Poster (11" X 17"): Highlights the Crime Victims Compensation Program and provides contact information. Intended for display in health-care, criminal-justice and social-service organizations. Can be downloaded and printed, or ordered from L&I. Smaller version is also available (8.5" X 11"). Get 11" X 17" poster printing tips.

 Poster
 F800-041-000
Help for Crime Victims (small poster)

Poster (8.5" X 11"): Highlights the Crime Victims Compensation Program and provides contact information. Intended for display in health-care, criminal-justice, and social-service organizations. Can be downloaded and printed, or ordered from L&I. Larger version is also available (11" X 17").

 Poster
 F800-104-000
Help for Victims of Crime / Ayuda para víctimas de crimen (English/Spanish)

Pamphlet/booklet: Answers questions about Washington State''s Crime Victims Compensation Program, who may be eligible for benefits and how to apply.

Pamfleto/folleto: Responde preguntas sobre el Programa de Compensación para Víctimas de Crimen del estado de  Washington, quienes podrían tener derecho a recibir beneficios y cómo pueden aplicar. 

 

 Publication
 F800-006-909
Hiring a Plumber? Hire Smart!

Worksheet: Provides advice and step-by-step hiring tips for homeowners planning a remodel, repair or addition to their home that involves plumbing. Tells homeowners how to verify that a construction contractor is registered and a plumber is certified with the state.

 Publication
 F627-044-000
Hiring teens? / ¿Piensa contratar adolescentes? (English/Spanish)

Fact sheet: Provides important information about hiring teens, including extra safety precautions, as well as legal requirements regarding minor work endorsement, hours and prohibited duties. Provides telephone, e-mail and Web contacts for more information.

 

 Publication
 F700-142-909
Historial de Trabajo (Enfermedad Ocupacional)

El trabajador lesionado llena este documento para presentar su historia de trabajo.  El formulario de continuación a esta página es F242-071-911.

 Form
 F242-071-999
Hoja para Contratar un Contratista con Éxito

Lista: Proporciona información para ayudar a  escrutinar  posibles contratistas para proyectos de construcción de casas o reparación/remodelación.  Presentado en un formato organizado y detallado.

 Publication
 F625-111-999
Home Modification for Workers with Catastrophic Injuries - Questions and Answers for Contractors

Fact sheet: Answers questions about the home modification benefit in Washington State''s workers'' compensation program and the bid process for contractors interested in this work.

 Publication
 F252-061-000
Homeowners Manufactured / Mobile Home Variance Request

This variance request applies only to the installations performed by a previous owner and does not apply to any home during the warranty period.

 Form
 F622-054-000
How To Calculate Your Wage in Agriculture

Fact/Information sheet: Shows piece rate workers how to calculate their wages to check if they are being paid minimum wage.

 Publication
 F700-171-000
How to Protest a Department of Labor and Industries Decision (English/Spanish) Cómo Protestar una Decisión en su Reclamo del Departamento de Labor e Industrias

Fact sheet: Explains how an injured worker can protest decisions on his/her claim and gives deadlines for taking action.

 Publication
 F242-363-909
Hydraulic Overpressure Test

To be submitted when a valve is changed or a seal is broken.

 Form
 F621-052-000
If Family Members Work for You, Know Your Obligations (English/Spanish) - Conozca sus Obligaciones Cuando Miembros de su Familia Trabajan para Usted

Fact sheet: Provides an overview and resources to know your obligations when you have family members working for you. Relatives, including children, must be treated as employees with the same rights as any other paid worker in the state of Washington.

 Publication
 F101-077-909
If Family Members Work for You, Know Your Obligations (English/Thai)

Fact sheet: Provides an overview and resources to know your obligations when you have family members working for you. Relatives, including children, must be treated as employees with the same rights as any other paid worker in the state of Washington.

 Publication
 F101-077-303
Independent Contractor Guide: A Step-by-Step Guide to Hiring Independent Contractors in Washington State

Pamphlet/booklet: A step-by-step guide to hiring independent contractors in Washington State. This publication is a general guide to help you understand how and when the Department of Labor & Industries applies workers’ compensation laws to independent contractors.

 Publication
 F101-063-000
Independent Medical Exam Doctor''s Estimate of Physical Capacities

IME Doctor’s Estimate of Physical Capacities: For use by independent examiners when asked to estimate physical capacities as part of an IME requested by the department.

 Form
 F242-387-000
Independent Medical Examination (IME) Provider Exam Sites

List the locations where the doctor does independent medical exams on a regular basis.

 Form
 F245-047-000
Individual Vocational Provider Account Change Form

To change an individual''s (service provider''s) name, add or delete referral categories, update certifications, leaving a firm, intern supervisor changes, and/or adding or deleting a branch for referrals.

 Form
 F252-021-000
Industrial Insurance Discrimination Complaint

Employees who believe they have been discriminated against by their employer use this form to file a complaint.

 Form
 F262-009-000
Injured by a third party?  

Brochure: Summarizes the legal rights and options an injured worker has if a third-party action pertains to his/her workers'' compensation claim. Includes the Third Party Election Form that must be completed by the worker. Note: The form must be printed, signed and mailed.

 Form
 F249-008-000
Injured by a third party?  

Brochure: Summarizes the legal rights and options an injured worker has if a third-party action pertains to his/her workers'' compensation claim. Includes the Third Party Election Form that must be completed by the worker. Note: The form must be printed, signed and mailed.

 Publication
 F249-008-000
Inquiry for Assessment of Damages

Your answers to these questions will be used to assist in evaluating your damages if a claim is made against a liable third party.

 Form
 F242-067-000
Inservice Inspection checklist

Inservice Inspection checklist for power boilers, low pressure boilers, pressure vessels, and hot water boilers.

 Form
 F620-060-000
Insignia Continuation Sheet Recreational Vehicles and Park Trailers

Continuation sheet to apply for an insignia.

 Form
 F622-021-111
Installation Application for Elevators

Used for installation application for elevators (new, renewals, and alterations).

Allow 30 business days for a response. Accuracy and completeness speeds up the processing time.
 
Residential Incline Chair Lifts: Allow one week for a response.

 Form
 F621-005-000
Instructions for completing the Workers'' Compensation Employer''s Quarterly Report

Instructions for completing the Workers'' Compensation Employer''s Quarterly Report. A sample of the form F212-055-000 is also available on the internet.

 Form
 F212-239-000
Instructor''s Report of Accident / Incident

This form must be submitted to L&I''s Apprenticeship Section by the Instructor at the time of the incident and the appropriate Apprenticeship Program within 5 days of an accident/incident of an apprentice/trainee during Related Supplemental Instruction (RSI).

 Form
 F100-509-000
Insurer Activity Prescription Form - Spanish Formulario de Restricciones Laborales del Asegurador

Used by Spanish speaking health-care providers to communicate an injured worker''s status, physical capacities, inability to work (time-loss) and treatment plans.

Utilizado por proveedores de cuidado de la salud que hablan español para indicar la condición actual del trabajador lesionado, restricciones físicas, certificación de tiempo perdido y planes de tratamiento.

 Form
 F242-385-909
Insurer Activity Prescription Form

Used by health-care providers to communicate an injured worker''s status, physical capacities, inability to work (time-loss) and treatment plans. To print an APF, click on the title of the form in the box above.

 Form
 F242-385-000
Interested Party Checklist for the Filing of Prevailing Wage Complaints

Checklist used for the filing of Prevailing Wage Complaints by "Interested parties" ONLY.

 Form
 F700-129-000
Intern Supplemental Application

Intern Supplemental Application

 Form
 F252-030-000
Internal Revenue Service Tax Compliance Certification

Form to gain Internal Revenue Service Tax Compliance Certification for registered Farm Labor Contractors. Now includes IRS form 8821 Tax Information Authorization.

 Form
 F700-098-000
Interpretive Services Appointment Record

This form is used when an interpreter is appointed to interpret for an injured worker during their medical visits.

When ordering, there is a limit of 4 pads, or 100 copies total. Fax your request to the L&I Warehouse at 360-902-4525 or email whsemail@Lni.wa.gov   Include the following in your request: Your name, mailing address, and telephone number and form number F245-056-000.

 Form
 F245-056-000
Irrevocable Standby Letter of Credit

Used by a self-insurer to provide collateral for its program only if it has a net worth in excess of $500 million.

 Form
 F207-112-000
Is it a Manufactured / Mobile Home?

If your home has any of the items in this document, it is a manufactured / mobile home and requires inspections for all alterations by L&I''s Factory Assembled Structures Section.

 Form
 F622-043-000
Job Analysis Summary

Summary that goes on top of a job analysis.  Gives the physician a snapshot of the physical demands of a job.

 Form
 F252-101-000
Job Analysis

Used by vocational rehabilitation counselors (VRCs) to document the physical demands of jobs.

 Form
 F252-072-000
Job Modification Assistance Application

For use by an vocational counselor, employer, etc. to request modification for the injured workers job. This may involve tools and equipment that is purchased through L&I.

 Form
 F245-346-000
Job Safety and Health Law - Spanish Ley de Seguridad y Salud en el Trabajo (English/Spanish)

Required poster: Describes important parts of the Washington Industrial Safety and Health Act (WISHA), which provides for job safety and health of Washington employees. Note: Employers in Washington State must display this poster where workers can see it. When ordering the printed version, you will receive one 22" X 17" poster that includes both languages.

Please order from L&I or print on 11" x 17" paper.

Get poster printing tips.

 Poster
 F416-081-909
Job Safety and Health Law - Spanish Ley de Seguridad y Salud en el Trabajo (English/Spanish)

Required poster: Describes important parts of the Washington Industrial Safety and Health Act (WISHA), which provides for job safety and health of Washington employees. Note: Employers in Washington State must display this poster where workers can see it. When ordering the printed version, you will receive one 22" X 17" poster that includes both languages.

Please order from L&I or print on 11" x 17" paper.

Get poster printing tips.

 Publication
 F416-081-909
Jorge''s New Job: Cholinesterase Testing in Washington State - Spanish Un Nuevo Trabajo para Jorge(English/Spanish)

Pamphlet/booklet: Uses a story format with dialogue and photographs to explain the hazards of cholinesterase-inhibiting pesticides, the state''s monitoring program and the importance of using proper safety equipment when working with pesticides.

 Publication
 F417-213-909
Journey Level Wage Rate from which apprentices'' wages rates are computed.

Used to submit the Journey-level wage rate from which the apprentices'' wage rate is computed. Form must be submitteed at least annually or sooner if the rates change.

 Form
 F100-050-000
Know What to Expect: How Recoveries and Settlements May Impact Your Crime Victim Claim

Pamphlet and form: Explains third-party liability, recoveries and settlements. A crime victim or the Crime Victims Compensation Program may pursue monetary restitution from someone who caused or contributed to a crime victim''s injury. Explains the purpose of the form and why individuals who file a crime victims claim are required to complete it.

 Publication
 F800-074-000
L&I Benefits for Workers Who Are Terminally Ill

Answers questions persons with a terminal illness may ask about benefits from L&I.

 Publication
 F252-094-000
Labor and Industries Prosthetic Device Request Form

Labor and Industries Prosthetic Device Request

 Form
 F245-340-000
Las Primas de Compensación para Trabajadores no Pagadas por su Subcontratista Podrían Ser su Responsabilidad

Hoja de información: Le informa a los contratistas de construcción cómo protegerse de la responsabilidad por las primas de compensación para los trabajadores no pagadas por su subcontratista.

 Publication
 F262-262-999
Letter of Intent for School Enrollment - Spanish Carta de Intención de Registro en una Escuela

Letter of Intent for School Enrollment - Spanish CARTA DE INTENCIÓN DE REGISTRO EN UNA ESCUELA

 Form
 F242-382-999
Licensed Elevator Contractor (LC) Operation

Contractors who install, construct, repair, alter or maintain elevators need to be licensed by the Elevator Program through L&I and with L&I''s contractor registration program.

 Form
 F621-069-000
Lista de Comprobacion para un Contratista de Trabajores Agrícolas (Farm Labor Contactor Checklist)

Lista de verificación para el contratista de trabajadores agrícola para asegurar el cumplimiento.

 Form
 F700-112-999
Llegar a un acuerdo sobre su reclamo de L&I puede ser lo correcto para usted - Una nueva opción para los trabajadores lesionados que tienen más de 55 años de edad (English/Spanish)

Panfleto/folleto: Explica el acuerdo sobre beneficios de compensación para trabajadores y proporciona un resumen de los requisitos que debe reunir y el proceso de solicitud y aprobación.  La audiencia para este folleto son los trabajadores lesionados los cuales pueden tener derecho a un acuerdo.

 Publication
 F240-003-999
Llevando a cabo su Plan vocacional: Sus derechos y responsabilidades durante el Plan de Implementación, Servicios de rehabilitación vocacional

Folleto: Explica lo básico de la etapa del plan de implementación de servicios vocacionales para trabajadores lesionados. L&I envia este folleto a los trabajadores lesionados cuando son referidos para servicios del plan de desarrollo. Se requiere que el consejero de rehabilitación vocacional asignado revise este folleto con el trabajador durante la reunión inicial en persona. 

 Publication
 F280-019-999
Lo Básico Sobre la Protección Contra Caídas en Actividades de la Industria de la Construcción

Proporciona un resumen de las normas modificadas de protección contra caídas y de los requisitos para las actividades en la construcción con fecha de vigencia del 1º de abril de 2013.

 Publication
 F414-154-999
Lo que Usted Debe Saber para Contratar a un Contratista, Remodelador o Empleado de Mantenimiento (Handyman)  

Hoja de información:  Proporciona una lista de verificación para los consumidores que están considerando contratar un contratista general o con especialidad, revisa el proceso de autorización y sugiere maneras para evitar problemas con gravámenes.  La ley estatal de Washington requiere que los contratistas de construcción se registren con L&I.

 Publication
 F625-084-999
Log of Good Faith Effort Documentation

This is for Registered Apprenticeship Programs to record Good Faith Effort activities in accordance with their Registered Apprenticeship Standards (Equal Employment Opportunity Plan)

 Form
 F100-515-000
Logger Safety Initiative Jobsite Notification

Members of the Logger Safety Initiative and landowners use this form to report their jobsite to L&I.

 Form
 F417-249-000
Logging Emergency Medical Plan (Logging Safety and Health Meetings)

Use this two part form for employers to record work locations and emergency rescue info and for holding safety meetings for each new jobsite

 Form
 F417-014-000
Long Term Care Assessment Tool

You must mail or fax form. No emailed forms are accepted. This assessment tool is provided by L&I assessment to determine the medically appropriate level of care that will meet the Injured Worker’s needs, abilities and safety in a residential facility. This assessment is not intended as a substitute for DSHS annual assessment & treatment plan, which is the sole financial responsibility of the facility.

 Form
 F245-377-000
Low Voltage Fire / Intrusion Alarm Checklist

This checklist is designed to be generic in content and may not include all requirements for your particular installation.

 Form
 F622-038-000
Lumber Handling in Sawmills

Book: Developed by mill workers, mill managers and L&I, this manual describes the risks of musculoskeletal injury in lumber-handling jobs. Identifies controls to reduce hazards,increase efficiency and reduce injuries.

 Manual
 F417-196-000
Mantenga a sus empleados seguros y trabajando

Panfleto/folleto:  Describe los beneficios de las consultas gratis para  empleadores que ofrece la División de Seguridad y Salud Ocupacional (DOSH, por su sigla en inglés) de L&I.  Estos servicios incluyen consultas de seguridad y/o higiene industrial, asistencia de ergonomía y recomendaciones sobre el manejo de riesgos en el sitio de trabajo.

 Publication
 F417-209-999
Manufactured Home Installer Certification Tag Order form

Manufactured Home Installer Certification Tag Order form

 Form
 F622-077-000
Manufactured Home Installer Certification Tag Transfer Request form

Manufactured Home Installer Certification Tag Transfer Request form

 Form
 F622-079-000
Manufactured Home Installer''s Monthly Certification Tag Report

Manufactured Home Installer''s Monthly Certification Tag Report

 Form
 F622-078-000
Maritime Coverage

Used by the employer as a quick reference guide to explain which maritime jobs may or may not be covered by L&I.

 Form
 F212-034-000
Maritime Coverage

Used by the employer as a quick reference guide to explain which maritime jobs may or may not be covered by L&I.

 Publication
 F212-034-000
Massage Therapy Treatment Authorization Fax Request

Used by a licensed massage practitioner/clinic to request authorization for outpatient massage therapy services for L&I claims.

 Form
 F248-357-000
Master Business Application

Link is to the Master Business License online form: Required for employers who hire minors and is obtained by completing the Master Business Application. Also available from L&I warehouse.

 Form
 BLSF-700-028
Mechanized Logging Supplemental Quarterly Report

Used by an employer to be submitted with the Employer''s Quarterly Report for Industrial Insurance as a supplemental reporting form.

 Form
 F212-223-000
Medical Device Review Request

This form is so L&I''s Office of the Medical Director can evaluate medical device(s) that the attending physican wants to use to treat an injured worker.

 Form
 F252-013-000
Medical Examiners'' Handbook

Book: A publication for independent medical examiners, attending doctors and consultants, this document contains guidelines, sample reports and billing procedures for preparing and conducting impairment ratings and independent medical exams in Washington''s workers'' compensation system. Beginning July 1, 2012, free Category I CME credits are available for completing the self-assessment associated with this handbook. Go to www.Imes.Lni.wa.gov and click on Medical Examiners Handbook for information on the exam. L&I and the authors have no financial interest or other relationship with the manufacturer(s) of any commercial product(s) and/or provider of commercial services discussed in this document. Find a medical examiner.

 Publication
 F252-001-000
Memorandum of Understanding Irrevocable Standby Letter of Credit

This memorandum of understanding is between a self-insurer and L&I regading the use of an irrevocable standby letter of credit by the self-insurer as surety for its self-insurance obligations.

 Form
 F207-113-000
Memorandum of Understanding

Used by a self-insured employer to signify the employer''s obligation and responsibilities in conjunction with providing an annuity as collateral for a total permanent disability claim.

 Form
 F207-129-000
Mental Health Fee Schedule and Billing Guidelines

Manual: This manual is for providers who bill the Crime Victims Compensation Program for mental health services for crime victims.

 Manual
 F800-105-000
Minimum Header Structural Requirements for Manufactured Home Alterations

For use on sidewalls only. Maximum of one new opening up to 11-6 wide per sidewall. Edge of opening to be no closer than 4 from end of sidewall.

 Form
 F622-080-000
Minimum Wage Law - Truck Drivers

Record keeping provisions and overtime for truck & bus drivers.

 Publication
 F700-095-000
Minimum Wage Law Exemptions

Covers exemptions to Washington state minimum wage law.

 Publication
 F700-051-000
Mobile Cranes/Derricks Worksheet for Construction Industry

Mobile Cranes/Derricks Worksheet for Construction Industry

 Form
 F416-043-000
Model Disclosure Statement Notice to Customer

This disclosure statement is given to the consumer (customer) from the contractor showing they are registered in the state of Washington. The consumer (customer) signs this form as acknowledgement of receipt.

 Form
 F625-030-000
Modificacion en el Trabajo Solicitud de Asistencia

Para ser utilizado por un consejero vocacional, empleador, etc. para solicitar modificación de empleo para el trabajador lesionado.  Esto puede incluir herramientas y equipo comprado por L&I.  

 Form
 F245-346-999
Modificacion en la vivienda Reconocimiento de responsabilidades

Utilizada tanto como por los trabajadores y contratistas de licitación para leer, firmar y someter a L&I para verificar que han leído, entendido y aceptado sus responsabilidades respectivas en el proceso de modificación de viviendas

 Form
 F247-003-999
Modificaciones de la vivienda para trabajadores con lesiones catastróficas – Preguntas y respuestas para contratistas

Hoja de información: Respuestas sobre el beneficio de la modificación de la vivienda del programa de compensación para los trabajadores del estado de Washington y el proceso de licitación para los contratistas interesados en el trabajo.

 Publication
 F252-061-999
Modificaciones de la vivienda para trabajadores con lesiones catastróficas

Hoja de información: Respuestas sobre el beneficio de la modificación de la vivienda del programa de compensación para los trabajadores del estado de Washington, quienes califican, lo que puede pagar L&I y donde obtener más información.

 Publication
 F252-060-999
Monitoreo de la Colinesterasa - Recomendaciones del Proveedor Médico (Formulario Muestra)

El proveedor llena este formulario.  Este formulario da recomendaciones por parte del proveedor sobre lo que necesita hacerse basado en los resultados de las pruebas hechas al empleado.

 Form
 F413-070-999
Monthly Supplemental Report for Manual Logging

Used by employers enrolled in the Logger Safety Initiative (LSI) to report manual logging hours monthly.

 Form
 F212-246-000
Multi-piece Rim Matching Chart

Poster for tire and rim servicing. To be displayed with  F417-237-000-A Demounting and Mounting Procedures for Tubeless Truck and Bus Tires and F417-237-000-B Demounting and Mounting Procedures for Tube-type Truck and Bus Tires. This poster must be printed at least 2''x3'' in size.

 Poster
 F417-237-000-C
Nail Gun Safety: A Guide for Construction Contractors

Booklet: Gives information needed to prevent nail gun injuries for construction employers.

 Publication
 F417-232-000
Necesita un doctor?

Tarjeta de información: Proporciona información a los trabajadores lesionados sobre con quien comunicarse si necesitan ayuda para encontrar un proveedor de cuidado de la salud que pueda darle tratamiento para su lesión o enfermedad ocupacional.  Este documento PDF imprime una hoja “8.5x11” que tiene 12 copias de la tarjeta.  Aviso: La información del descargo de responsabilidad en la página 2 puede que no esté alineada correctamente con la impresión en ambos lados.

 Publication
 F160-006-999
Need a Doctor?

Information card: Provides contact information for injured workers needing assistance in finding a health-care provider who will treat their occupational injury or disease. This PDF will print out an 8.5" X 11" sheet that has 12 copies of the card. Note: Disclaimer information on Page 2 may not line up accurately in two-sided printing.

 Publication
 F160-006-000
New Elevator Installation Checklist

Checklist for the elevator company/contractor to complete before the call L&I for an elevator inspection. Includes December 2010 letter on ASME checklists.

 Form
 F621-057-000
New/Update Elevator Company Primary Point of Contact

Used by the Elevator Section only to Change and/or Update the Primary Point of Contact for Elevator Companies

 Form
 F621-086-000
Non-accredited or Unlicensed Training Provider Application Supplemental Requirements

Used by non-accredited or unlicensed training providers in order to be reviewed for approval to become a training provider for Washington injured workers. Must be submitted with the Provider Account Application (F248-011-000).

 Form
 F280-045-000
Non-Network Provider Application

Includes the F248-036-000 Statewide Payee Registration and W-9 form. For providers to complete that do not want to become a Labor and Industries network provider, or for a specialty that L&I is not accepting network applications for at this time. If you are applying to be a Labor and Industries network provider, please complete application process at www.ProviderNetwork.Lni.wa.gov

 Form
 F248-011-000
Nonagricultural Employment of Minors Chapter 296-125 WAC

Nonagricultural Employment of Minors Chapter 296-125 WAC

 Manual
 F700-084-000
Notice of Completion of Public Works Contract

This is the form used by public agencies to request L&I''s approval to release retainage. All contractors are to be listed on the request form with their associated affidavit id number.  Notices received without affidavit id numbers or incomplete information will not be processed and will be returned to the awarding agency. The first EXCEL document is in Office 2007 format. The second file, with the same title, is in Office 2003 format.

 Form
 F215-038-000
Notice of Contest or Objection to Proposed Standards of Apprenticeship

Used by competitor to contest or object to a proposed standards of apprenticeship, new occupation or revised geographical area. Submit this form at least 20 days prior to a Council meeting.

 Form
 F100-516-000
Notice of Occupational Disease or Infection

Used by medical providers to notify L&I that an occupational disease or infection has been diagnosed and that the worker has been advised that their condition may be work-related. This form can be used if the worker does not complete a Report of Accident or Occupational Disease (ROA) but should not be completed in place of an ROA.

 Form
 F242-243-000
Notice to Attending Physician of Apprentice / On-the-Job-Training Accident / Incident

A notice to the attending physician that the individual is a Registered Apprentice and to attach this form to the Accident Report of Industry Injury or Occupational Disease (F242-130-000).

 Form
 F100-511-000
Notice to Employees -- If a Job Injury Occurs/Aviso a los empleados--Si Ocurre una Lesión en el Trabajo (English/Spanish)

Required poster: Outlines the steps a worker should take if a job-related injury or illness occurs. Also briefly describes the benefits available through Washington''s workers'' compensation system. Note: ''Employers who receive industrial insurance coverage from L&I must display this poster where workers can see it. English and Spanish online versions will print separately.

 Poster
 F242-191-909
Notice to Employees -- If a Job Injury Occurs/Aviso a los empleados--Si Ocurre una Lesión en el Trabajo (English/Spanish)

Required poster: Outlines the steps a worker should take if a job-related injury or illness occurs. Also briefly describes the benefits available through Washington''s workers'' compensation system. Note: ''Employers who receive industrial insurance coverage from L&I must display this poster where workers can see it. English and Spanish online versions will print separately.

 Publication
 F242-191-909
Notice to Employees -- Self-Insurance/Aviso a los Empleados -- Seguro Industrial Propio (English/Spanish)

Required poster for self-insured businesses: Outlines what a worker employed by a self-insured business should do if a work-related injury or illness occurs. Note: Self-insured employers must display this poster where workers can see it.

 Poster
 F207-037-909
Notice to Employees -- Self-Insurance/Aviso a los Empleados -- Seguro Industrial Propio (English/Spanish)

Required poster for self-insured businesses: Outlines what a worker employed by a self-insured business should do if a work-related injury or illness occurs. Note: Self-insured employers must display this poster where workers can see it.

 Publication
 F207-037-909
Notificación de Decisión de Cierre con Discapacidad Parcial Permanente para Empleadores Autoasegurados - PPD-NTL

Usada solamente por los empleadores autoasegurados o sus representantes, esta es una notificación legal para un trabajador lesionado indicando que su reclamo está cerrado.  Esta orden se usa solamente cuando no se ha pagado compensación de tiempo perdido pero se está pagando una indemnización por discapacidad parcial permanente.

 Form
 F207-165-999
Notificación de Decisión de Cierre con Discapacidad Parcial Permanente para Empleadores Autoasegurados - PPD-TL

Usada solamente por los empleadores autoasegurados o sus representantes, esta es una notificación legal para un trabajador lesionado indicando que su reclamo está cerrado.  Esta orden se usa solamente cuando se ha pagado compensación de tiempo perdido y también se está pagando una indemnización por discapacidad parcial permanente.

 Form
 F207-164-999
Notificación de Decisión de Cierre para Reclamos Únicamente Médicos para Empleadores Autoasegurados

Usada solamente por los empleadores autoasegurados o sus representantes, esta es una notificación legal para un trabajador lesionado indicando que su reclamo está cerrado con beneficios médicos solamente.  Esta orden se usa solamente cuando no se ha pagado compensación de tiempo perdido ni tampoco indemnización por discapacidad parcial permanente.

 Form
 F207-020-999
Notificación de Decisión de Cierre para reclamos de Tiempo Perdido para Empleadores Autoasegurados

Usada solamente por los empleadores autoasegurados o sus representantes, esta es una notificación legal para un trabajador lesionado indicando que su reclamo está cerrado.  Esta orden se usa solamente cuando se ha pagado compensación de tiempo perdido pero no se está pagando una indemnización por discapacidad parcial permanente.

 Form
 F207-070-999
Notification to Local Enforcement Agency

L&I sends this form to notify the local agencies when a factory-built structure is being shipped within a county or city limits.

 Form
 F623-013-000
Occupational Disease & Employment History

Injured worker fills this out to document possible occupational disease and to show work history.

 Form
 F242-071-000
Occupational Disease Employment History of Hearing Loss and Continuation Sheet - Spanish - Historia de Trabajo - Pédida de Audición

Hoja de continuación del formulario, Historia de la pérdida de audición.

 Form
 F262-013-999
Occupational Disease Work History - Continuation

This is a continuation page to the Occupational Disease Work History (F242-071-000) to add additional work history.

 Form
 F242-071-111
Occupational or Physical Therapy Treatment Authorization Fax Request

Used by a therapy provider/clinic to request authorization for outpatient occupational or physical therapy services for L&I claims.

 Form
 F248-055-000
Office Locations

Fact sheet: Shows which L&I region serves which counties and the location of offices. Side Two lists the address and telephone number for each office.

 Publication
 F101-100-000
OJT Accountability Agreement - Spanish Acuerdo de Responsabilidad de la Capacitación Durante el Transcurso del Trabajo

Acuerdo de responsabilidad de la capacitación durante el transcurso del trabajo en español.

 Form
 F280-029-999
OJT Information Request and Recommendation form

VRCs can use this form to request information on a specific on -the -job (OJT) training opportunity listed on L&I''s website, or to recommend an OJT training opportunity.

 Form
 F280-032-000
On the Job Training Accountability Agreement

This form is for OJT training plans, and must be signed by the worker and VRC then sent in along with your training plan to L&I for approval. For non-OJT retraining plans, please refer to form F280-016-000.

 Form
 F280-029-000
On-The-Job Training (OJT) Agreement for Vocational Providers

On-The-Job Training (OJT) Agreement for Vocational Providers

 Form
 F280-039-000
On-the-Job Training Agreement Card

This card is used by an OJT Apprenticeship program ONLY. To receive this form, you must contact the Apprenticeship Section.

 Form
 F100-019-000
On-The-Job Training Work Hours

Used to report the work hours for an on-the-job training employee.

 Form
 F100-229-000
Opioid Treatment Agreement

Use this treatment agreement when starting chronic opioid therapy. It should be renewed yearly or when there is a new prescriber.

 Form
 F252-095-000
Option 2 Vocational Benefits Training Enrollment Application and Verification

State fund workers who have selected Option 2 and closed their claim can use this form to apply for access to their Option 2 training funds. To seek reimbursement, use form F245-030-000 Statement for Retraining and Job Modification Services.

 Form
 F280-024-000
Option 2 Vocational Benefits Training Enrollment Application/Aplicación y Verificación del Registro (English/Spanish)

State fund workers who have selected Option 2 and closed their claim can use this form to apply for access to their Option 2 training funds. To seek reimbursement, use form F245-030-000 Statement for Retraining and Job Modification Services.

 Form
 F280-024-909
Out of Country Provider Application

This application is for providers outside the United States. Providers who treat injured workers must have a provider number to bill the department.

 Form
 F248-361-000
Overpayment Reimbursement Fund Request Coversheet

This form is a coversheet used by Self-Insurance for overpayment reimbursement fund requests.

 Form
 F207-212-000
Owner Requested Red Tag Form

Used by the owner for red tagging a unit that is to be placed or to remain out of service.

 Form
 F621-063-000
P&R:Comunicación sobre los Riesgos Químicos

Hoja de información: Proporciona información sobre cambios a los reglamentos federales de comunicación de la Administración de Seguridad y Salud Ocupacional (OSHA, por su sigla en inglés), los cuales causan la necesidad para cambios en la norma del estado de Washington.  Se proyecta que los cambios mejoren el entendimiento de la información de peligro que se encuentra en las etiquetas de los productos para prevenir más efectivamente las lesiones, enfermedades y muertes.

 Publication
 F417-242-999
Panel Load Calculations

Listing of Connected Loads and the Demand Loads. Used for all appliances that are fastened in place, permanently connected on specific circuit. Single Phase Panel Schedule and Three Phase Panel Scheule inlcude. Sample diagram included.

 Form
 F623-017-000
Parent / School Authorization for Employment of a Minor and Special Variance

For legal guardians and school officials to approve the hours and work activities for a minor employee to work according to terms listed by the employer. The Special Variance allows additional hours of work for 16- and 17-year-olds and is described on the form. All parties must sign to approve the hours of work for a minor regardless of the number of hours listed. This is NOT a work permit. Employers must obtain a minor work permit endorsement on their Master Business License where they employ workers under 18.

For hiring youth only during non-school weeks, you may use form F700-168-000 Parent Authorization Summer Work  

 Form
 F700-002-000
Parent Authorization Summer Work

This form is for summer employment of minors, only, and is for parents or legal guardians to approve the hours and work activities for a minor employee to work according to terms listed by the employer.  All parties must sign to approve the work schedule and duties for a minor prior to permitting them to work.  This is NOT a work permit.  Employers must obtain a minor work permit endorsement on their Business License where they employ workers under 18.

 Form
 F700-168-000
Payment of Wages - RCW 49.48.010 and 49.52.050

This is a copy of the law that pretains to the payment of wages to an employee when they stop working for an employer. The wages due to the employee for the pay period worked prior to leaving.

 Form
 F700-064-000
Payroll Service Provider - Quarterly Reporting Bulk Filing Enrollment Form

Used by payroll services to enroll and register with L&I for downloading/uploading account information from the Express Filing site using an electronic list (text file) of accounts.

 Form
 F248-343-000
Peligro - Área en Construcción - Solamente Personas Authorizadas

Large words: Peligro - Área en Construcción -  Solamente Personas Authorizadas. Get poster printing tips.

 Poster
 FSP1-013-999
Pension and Survivor Benefits in Washington State''s Workers'' Compensation Program--English/Spanish (Beneficios de Pensión y para Sobrevivientes del Programa de Compensacin para Trabajadores de Washington)

Pamphlet/booket: Answers the most common questions about pension and survivor benefits under Washington''s workers'' compensation program.

 Publication
 F242-352-909
Pension Benefits Questionnaire - Spanish Cuestionario para Beneficios de Pensión

Usado por un trabajador lesionado que recibe una orden estableciendo que el o ella está total y permanentemente discapacitado.  Este cuestionario debe completarse en su totalidad y deben adjuntarse todos los documentos necesarios antes de que puedan calcularse sus opciones de beneficios de pensión.

 Form
 F242-393-999
Pension Benefits Questionnaire

Used by an injured worker who receives an order that states he or she is totally permanently disabled. This questionnaire must be completed in full and all necessary documents attached before his or her pension benefit options can be calculated.

 Form
 F242-393-000
Performance Based Physical Capacities Evaluation

Used by occupational and physical therapy providers as an optional reporting format for a Performance-based Physical Capacities Evaluation.

 Form
 F245-023-000
Permanezca en el Trabajo: Una Solución Factible -- Un programa para ayudar a los empleadores a mantener a los trabajadores lesionados en el trabajo -- paga la mitad del salario base además de otros gastos

Panfleto/folleto: Proporciona un resumen del programa Permanezca en el trabajo, un programa con un incentivo económico que exhorta a los empleadores del estado de Washington a encontrar trabajos livianos o de transición para trabajadores que se están recuperando de lesiones ocurridas en el trabajo. Incluye información sobre los requisitos que deben reunir, cómo hacer una solicitud y donde pueden obtener más información.

 Publication
 F243-006-999
Permit Refund Request

A form to request a refund for an electrical work permit, elevator permit, or factory-assembled structure alteration permit.

 Form
 F621-105-000
Physical Exam - Charter Boat Operators License

This form is used by applicants applying for a charter boat operators license to have completed by a physician for an operators license

 Form
 F416-056-000
Physical Therapy / Occupational Therapy Progress Report to Claim Managers

The physical / occupational therapist uses this report to identify the clinical goals and return to work objectives of the injured worker.

 Form
 F245-059-000
Plan Approval Request - Conversion Vendor / Medical Units

Used in requesting a plan approval for Conversion Vendor or Medical Unit factory-assembled structures.

 Form
 F622-035-000
Plan Approval Request - Factory Built Structures and Commercial Coaches

A manufacturer of factory-built structures and/or commercial coaches uses this form to submit plans to L&I for review.

 Form
 F623-006-000
Plan Approval Request - Recreational Vehicles and Recreational Park Trailers

Plans to build recreational vehicles or park trailers need approval from L&I. This form is used as part of the approval process.

 Form
 F622-006-000
Plan de Desarrollo: ¿Cuáles son mis Derechos y Responsabilidades? Servicios de Rehabilitación Vocacional

Folleto: Explica lo básico de la etapa del plan de desarrollo de servicios vocacionales para trabajadores lesionados.  L&I envia este folleto a los trabajadores lesionados cuando son referidos para servicios del plan de desarrollo.  Se requiere que el consejero de rehabilitación vocacional asignado revise este folleto con el trabajador durante la reunión inicial en persona. 

 Publication
 F280-018-999
Plan Development Quality Assurance Review Form

For use internally by L&I Vocational Service Specialists (VSSs) to determine if all required components are included in the submitted plan. Can be used by VRCs as a tool. DO NOT SUBMIT TO L&I.

 Form
 F280-007-000
Plan for and Pay Your Taxes DVD

DVD: Covers state business taxes and workers'' compensation premiums and provides information on how to file. This 28-minute DVD can help employers plan ahead and obtain more information.

 DVD
 F101-091-034
Plumber Continuing Education Course Application

This form is used by the course sponsor to submit continuing education courses for plumber certification.

 Form
 F627-037-000
Plumber, Medical Gas, or Trainee Renewal

This form is used to renew a plumber certification, plumber trainee or medical gas installer certification.

 Form
 F627-019-000
Plumbers Examination Dates and Locations

The 2014 Plumber Examination Dates and Locations. A printed version is also available from the L&I Warehouse.

 Form
 F627-027-000
Pocket Guide to Caution Zone Jobs

Pamphlet/booklet: This advisory pocket guide reviews 14 workplace risk factors that can lead to soft tissue injuries such as back strain, tendinitis and carpal tunnel syndrome. Suggests ways to identify the risk factors. Lists helpful resources from L&I.

 Publication
 F417-195-000
Poison Oak Poster (English/Spanish) Cartel sobre el Zumaque Venenoso

Full-color photographs of poison oak in different seasons help workers recognize and avoid the plant when working outdoors. Note: Poster will split over two pages if printed on 8.5" X 11" paper. Get poster printing tips.

 Poster
 F413-045-000
Poster - An Unprotected Trench is an Early Grave

Poster: Trench safety information for employers. Features tips to prevent cave-ins, and proper inspection proceedures. Get poster printing tips.

 Poster
 FSP0-912-000
Pre-Audit Questionnaire

Pre-Audit Questionnaire. The fillable MSWord version is saved in the 2003 format. The EXCEL file is saved in ExCEL 2007 format. There is also a fillable PDF version.

 Form
 F213-177-000
Pre-Inspection Checklist for High Pressure Boilers

Checklist which reflects the most common violations found by Field Inspectors. This checklist should be gone through prior to calling for an inspection of High Pressure Boilers

 Form
 F620-053-000
Pre-Inspection Checklist for Low Pressure Steam Boilers

Checklist which reflects the most common violations found by Field Inspectors. This checklist should be gone through prior to calling for an inspection of Low Pressure Steam Boilers

 Form
 F620-052-000
Pre-Job Accommodation Assistance Application

For use by a therapist or vocational provider to request job modification for an injured worker before the injured workers is employed, possibly in a retraining program. This may involve tools and equipment that is purchased through L&I.

 Form
 F245-350-000
Preauthorization Request for Services for State Fund Workers'' Compensation Patients

This form can only be used for services that can be authorized by the claim manager and it should not be used for Utilization Review (Qualis), Provider Hotline or requests to the Occupational Nurse Consultant.  If you are unsure of what services need to be authorized see L&I fee lookup utility at www.Lni.wa.gov/apps/FeeSchedules/

For complete information on all authorization processes please see:  www.Lni.wa.gov/ClaimsIns/Providers/AuthRef/GetAuth.asp

 Form
 F242-397-000
Preferred Worker Benefit Frequently Asked Questions

Fact sheet: Includes information regarding the benefits of Preferred Worker certification, answers to questions frequently asked by workers, phone and website contacts.

 Publication
 F280-052-000
Preguntas frecuentes sobre el Beneficio del Programa de Incentivos para Volver a Emplear Trabajadores Lesionados

Hoja de información: Incluye información relacionada con los beneficios de la certificación de beneficios del programa de incentivos para volver a emplear trabajadores lesionados, respuestas a preguntas frecuentes de los trabajadores, información de teléfonos y del sitio Web.

 Publication
 F280-052-999
Preparing for Your Self-Insurance Audit

Pamphlet/booklet: Helps self-insured employers understand and prepare for an audit.

 Publication
 F207-110-000
Prevailing Wage Complaint and Instructions

Ask L&I to conduct an investigation into a prevailing wage violation that affects one or more employees. See box 30 on the form to see what types of complaints are covered.

 Form
 F700-146-000
Prevailing Wage Complaint Instructions - Spanish - Instrucciones para el Registro de una Queja Sobre Salario Prevaleciente

Pídale a L&I que haga una investigación de un asunto relacionado con el salario prevaleciente que afecte a uno o más empleados.

 Form
 F700-146-999
Program Equal Employment Opportunity Activity Documentation

Used to record individual equal employment opportunity activities conducted by Apprenticeship Programs.

 Form
 F100-012-000
Programa con Incentivos para Reemplear Trabajadores Lesionados

Panfleto/folleto:  Describe el Programa con incentivos para reemplear trabajadores lesionados y los beneficios que reciben los empleadores cuando contratan trabajadores con el programa.  En general, estos son trabajadores cuyas lesiones o enfermedad ocupacional les impide regresar a su antiguo trabajo. 

 Publication
 F280-021-999
Property Owner Electrical Work Permit Application

This application is used to apply for a valid electrical permit. 5 pages.

 Form
 F500-094-000
Protect My Home Hire Smart Worksheet

Checklist: Provides information to help screen potential contractors for home construction or repair/remodel projects. Presented in an organized, step-by-step format.

 Publication
 F625-111-000
Protected Leave Complaint Form - Spanish - Queja sobre el Permiso de Ausencia Protegida

Para quejas de ausencia del trabajo: Descargue y complete un formulario de Queja sobre permiso de ausencia protegida (F700-144-999)

 Form
 F700-144-999
Protected Leave Complaint

For leave from work complaints: Download and complete a Protected Leave Complaint form (F700-144-000)

 Form
 F700-144-000
Protesting Retro Adjustments

Fact sheet: Provides important information to employers and Retro groups about the process the department follows when considering an adjustment protest.

 Publication
 F250-027-000
Provider Account Application - Independent Medical Examiner (IME)

In order to do independent medical exams a provider must obtain a provider account number with L&I. This packet includes the application and agreement with instructions, IME Provider Exam sites form (F245-047-000) and Request for Taxpayer ID and Certification - Form W-9 (F248-036-000) (10 pages). If you have questions, please email balk235@lni.wa.gov or call 360-902-6815.

 Form
 F245-046-000
Provider Application and Notice for new firms

Complete this application and the StateWide Payee W-9 if you are applying for a firm Provider Number with L&I.

 Form
 F252-088-000
Provider Change Form for Crime Victims Compensation

Providers use to inform L&I that they have changes to their account. Such as changes to their Tax ID address/name, business address, billing address, name, or termination of account. This also includes a W-9 form.

 Form
 F800-089-000
Provider Credentialing Change Form

Providers use this form to notify L&I of a change of their business address, billing address and account termination. Also has info on how to notify L&I on a tax ID (EIN) number change, tax ID address change and/or name change.

 Form
 F245-365-000
Provider''s Initial Report (PIR)

Used by medical providers when reporting initial treatment for an industrial injury or occupational disease for a self-insured claim. The paper version dated 10-2012 is still valid, as is the 01-2014 word fillable version.

Medical providers treating self-insured workers, self-insured businesses, or their third party claims administrators can access this form one of two ways:

  1. Download the Microsoft (MS) Word form and the PDF file with instructions:

           The first file is the PDF instructions.

           The second file is an Office 2003 MSWord document ending in .doc.

           The third file is an Office 2007/2010 version, ending in .docx.

2.  Order paper copies of this form by clicking the “order it” button.

 Form
 F207-028-000
Provider''s Request for Adjustment

Providers use this to report total overpayment, partial overpayment and/or underpayment by L&I.

 Form
 F245-183-000
Put this Guard Back - 5 1/2 x 2 1/8 inches

Sticker: 5 1/2 inches X 2 1/8 inches

 Sticker
 FSP0-993-001
Put this Guard Back - 8.5 x 3.5 inches

Sticker: 8.5 inches X 3.5 inches

 Sticker
 FSP0-993-000
Q&A: Cranes, Rigging and Personnel Lifting Rule, Chapter 296-155 WAC, Part L

Q&A Factsheet: Answers to questions crane or derrik operators/owners might have regarding vehicle/operator certification and training required for cranes and derriks based on possible construction site scenerios.

 Publication
 F417-245-000
Q&A: Hazard Communication Standard

Fact sheet: Provides information about changes to OSHA''S Federal Hazard Communication Standard, which triggers the need for changes to Washington State''s standard. Rulemaking is under way in 2013. The changes are intended to improve comprehension of hazard information found in product labels to more effectively prevent injuries, illnesses and fatalities.

 Publication
 F417-242-000
Q&A: Stay of Abatement Date

Fact sheet: Explains how an employer requests a "stay of abatement date." Effective July 1, 2012, an employer must fix a hazard cited in a workplace inspection during appeal unless he or she has requested and been granted a stay of abatement date.

 Publication
 F417-235-000
Quarterly Report for Self-Insured Business

Form used to submit Quarterly Report. If you need a copy of this form to complete your quarterly report, please contact Certification Services at 360-902-6867.

 Form
 F207-006-000
Quarterly Reporting for Drywall

Used by drywall employers as a guide to completing quarterly and supplemental reports. This includes filled out samples of F212-050-000 and F212-051-000.

 Form
 F212-224-000
Quarterly Statement of Supplemental Benefits Instructions

Instructions for filling out the quarterly statement of supplemental benefits.

 Form
 F207-011-111
Quarterly Statement of Supplemental Benefits Paid for Self-Insured Employers

Used by self-insured employers to report their quarterly statement of supplemental benefits.

 Form
 F207-011-000
Queja por Discriminación de Seguro Industrial

Los empleados que piensan que han sido discriminados por su empleador pueden usar este formulario para presentar una queja.

 Form
 F262-009-999
Queja por Suprimir un Reclamo - Spanish - Claim Suppression Complaint

Un trabajador lesionado puede someter  este formulario si su empleador ha suprimido su derecho a presentar un reclamo por una lesión.

 Form
 F262-024-999
Quick Reference Card for Providers

Flyer or small poster for administrative staff for health-care and vocational providers: lists the most frequently used procedure codes and fees. The back highlights the most popular or frequently used web pages for providers and their staff. Provides tips for speeding up authorizations and for billing self-insured employers.

 Publication
 F245-414-000
Quick Tips for Lifting/Consejos Breves para Levantar Cargas (English/Spanish)

Fact sheet: Provides 10 tips for safer lifting. Contains illustrations.

 Publication
 F417-055-909
QuickFile: Workers'' Compensation Quarterly Report Filing Made Easy!

Rack card: Information to help employers file their Workers'' compensation quarterly report online. Includes filing webpages links and deadlines.

 Publication
 F212-244-000
Reassignment of Savings Account or Time Deposit - Construction Contractors

Contractors may use this form to request changes to a Assignment of Savings that was filed in lieu of a surety bond or insurance policy.

 Form
 F625-011-000
Reassignment of Savings Account or Time Deposit - Electrical Contractor

A reassignment is permitted only when (1) the Electrical Contractor (assignor) changes the name of the business; (2) the Electrical Contractor transfers the funds to a new account; or (3) the financial institution changes the account number.

 Form
 F500-072-000
Reclamo para Beneficios de Pensión Presentado por los Dependientes

Usado por los dependientes de un trabajador fallecido para presentar un reclamo para beneficios.

 Form
 F242-062-999
Record Keeping Provisions - Employment Standards

This form is for employers to use to keep records on every employee.

 Form
 F700-009-000
Referral for WorkSource Services from Private Vocational Provider

Used by private Vocational Providers to refer injured workers to WorkSource

 Form
 F280-046-000
Reforestation Contract Supplemental Report - Forest, Range and Timber Industry

Used by an employer to report worker hours for each individual contract with a timber landowner. This is a supplemental document to the Contract: Report by Contractor - Forest, Range & Timber Industry (F213-011-000).

 Form
 F213-013-000
Reforestation Industry Continuation Sheet (Over $10,000)

Used by contractors to report contracts over $10,000. Reforestation industry contractors must report worker hours for each individual contract with a timber landowner. This form should accompany the quarterly report.

 Form
 F213-015-000
REFUND NOTIFICATION Refunding Money to L&I to correct your account?

Used to Refund Money to L&I to correct your account REFUND NOTIFICATION

 Form
 F245-043-000
Registered Apprenticeship in the Construction Industry

Brochure: Designed for construction business employers who are interested in hiring apprentices. Includes answers to common questions, how to hire apprentices, the benefits of apprenticeship, testimonials, and contact information.

 Publication
 F100-533-000
Registered Apprenticeship Program Address/Mailing Information Update

Used by the Registered Apprenticeship Program to update their address or mailing information. (Note: This DOES NOT update your program standards information.) You should ensure that your address information in the Standards is correct.

 Form
 F100-512-000
Registered Contractor Card

This is a fillable version of the Registered Contractor Card

 Form
 F625-069-000
Regresando a Trabajar es su Trabajo y su Futuro

Panfleto/folleto:  Explica brevemente los pasos para regresar a trabajar rápidamente y reducir el impacto económico del tiempo perdido.  También proporciona recursos útiles.  Destinado para trabajadores lesionados.

 

 

 Publication
 F200-001-999
Related Supplemental Instruction / On-the-Job Training Hours

Used to track apprentices/trainees on-the-job training hours.

 Form
 F100-518-000
Related Supplemental Instruction Hours

Used by Apprenticeship programs to submit related instruction hours to L&I Apprenticeship section. It is preferred that programs use the combined RSI/OJT reporting form. RSI Hours must be reported quarterly.

 Form
 F100-228-000
Renewal Application for Contractor Registration

Renewal Application for Contractor Registration

 Form
 F625-107-000
Renewal of Contractor Elevator License

Used by Elevator Companies to renew their Contractor License.

 Form
 F621-082-000
Renewal of Elevator Mechanic License

Used by elevator mechanics to renew their license if they do not want to use the online "Get or Renew a License".

 Form
 F621-080-000
Rental Boiler Operating Permit - Good at this Location Only

To request a permit to use a rental boiler at one location only.

Allow 24 hours for a response. Accuracy and completeness speeds up the processing time.

 Form
 F620-042-000
Report All Injuries Promptly / Reporte Todas las Lesiones Inmediatamente (English / Spanish)

Large words: Report All Injuries Promptly. Get poster printing tips.

Palabras en tamaño grande: Reporte todas las lesiones inmediatamente.  Obtenga información sobre cómo imprimir carteles.

 Poster
 FSP1-004-999
Report of Accident (ROA) Workplace Injury, Accident or Occupational Disease

This form is not available to download. If you are an injured worker, ask your medical provider for a copy of this form or you can complete your portion of the Report of Accident (ROA) online at https://secure.Lni.wa.gov/home

 Form
 F242-130-000
Report of Accident Instructions -- Spanish Instrucciones para el Reporte de Accidente

Este documento proporciona instrucciones en español sobre como completar solamente la porción del trabajador en el Reporte de accidente (ROA, por su sigla en inglés).  Por favor note que el Reporte de Accidente no está disponible en español.

 Form
 F242-130-999
Reporte Trimestral para la Industria de Tabla de Yeso

Used by drywall employers as a guide to completing quarterly and supplemental reports. This includes filled out samples of F212-050-000 and F212-051-000.

 Form
 F212-224-999
Request for Archive Records - Contractor Registration

This form is to request L&I to release archive records in the contractors registration section.

 Form
 F625-094-000
Request for Assistance in Obtaining Certified Payroll Records

Used to request copies of Certified Payrolls for prevailing wage projects.

 Form
 F700-141-000
Request for Change of Address

Used by electrical licensee to notify L&I of an address change.

 Form
 F500-044-000
Request for Change of Status - Apprenticeship/Training Agreements and Training Agents

Used to request a change of status for apprentices, the training agreements or the training agents. These are normally accompanied by Committee meeting minutes when submitted.

 Form
 F100-021-000
Request for Claim Information

Used by workers, workers'' representatives, employers or employers'' representatives to request claim information from L&I.

 Form
 F101-010-111
Request for Duplicate Elevator Certificate

Used to request a duplicate elevator license or a duplicate operating permit for a conveyance.

 Form
 F621-065-000
Request for Duplicate Elevator Mechanic License

Request for Duplicate Elevator Mechanic License

 Form
 F621-099-000
Request for Duplicate or Replacement Certificate

This form is used to request a duplicate or replacement certificate for a plumber or plumber trainee.

 Form
 F627-014-000
Request for Duplicate or Replacement License or Certificate

To request a duplicate or replacement of your Washington state electrical license or certificate.

 Form
 F500-032-000
Request for Manuals from Claims Training

Fillable form to purchase the Workers’ Compensation Adjudicator (WCA), Claims Management (CM), and Policy Manuals (all 3 manuals on 1 CD) the costs will be added up automatically, the total amount enclosed column will be the amount you need to send as payment.

 Form
 F241-021-000
Request for Preferred Workers Status

Used by vocational providers to apply for preferred worker status on behalf of an industrially injured worker.

 Form
 F280-023-000
Request for Public Records

To request public records from Washington State Dept. of Labor and Industries. You can order an earlier version from the LNI warehouse until stock is exhausted.

 Form
 F101-009-000
Request for Recognition of Apprenticeship Committee

Used to establish a new apprenticeship committee and list it''s employer/employee representatives.

 Form
 F100-504-000
Request for Revision of Committee

Used to request revision of committees to include changing the title of the standards, sub-committee members, and committee members.

 Form
 F100-031-000
Request for Survivor Counseling Benefits (English/Spanish) Solicitud para Beneficios de Apoyo para los Sobrevivientes  

Used by immediate family members of homicide victims to request mental health counseling.

 Form
 F800-057-909
Reservation Form Safety and Health Video Library

Use this form to make reservations of safety and health videos. There is both a fillable MS Word form that you can email in, and a fillable PDF that you can fill and print.

 Form
 F417-206-000
Resumen de las Leyes de Salario Prevaleciente en Lenguaje Sencillo Entienda sus Responsabilidades y Derechos al Hacer Trabajos Públicos

Hojas 8.5 pulgadas x 11 pulgadas: Proporciona un resumen de las leyes y normas del salario prevaleciente en español.  Esta publicación está solamente disponible en español.  Para información similar en inglés, lea el folleto de la ley de salario prevaleciente del estado de Washington.

 Publication
 F700-152-999
Retrospective Rating Adjustment Protest

Used by employers to present L&I with a list of decisions they are protesting by adjustment period. The form requests all necessary elements needed for L&I to process a request for reconsideration.

 Form
 F250-024-000
Risk Management Consultation

Pamphlet/booklet: Describes the benefits of free risk management consultations. L&I’s Risk Managers can provide: data and analysis specific to your business that shows how claims can affect the premiums you pay; show you the cost/benefit of claim management strategies; identify return-to-work options and resources; and review best practices in hiring strategies and procedures.

 Publication
 F417-246-000
Robos y Clientes Abusivos: Consejos para Prevenir Lesiones

Consejos sobre cómo manejar el dinero en efectivo y cómo tener un restaurante o un entorno minorista más seguro.  Obtenga información sobre cómo imprimir carteles.

 Poster
 FSP0-919-999
Robos y Clientes Abusivos: Consejos para Prevenir Lesiones

Consejos sobre cómo manejar el dinero en efectivo y cómo tener un restaurante o un entorno minorista más seguro.  Obtenga información sobre cómo imprimir carteles.

 Publication
 FSP0-919-999
Roof Affidavit and Structural Inspection Request

The purpose of the manufactured home roof affidavit is to provide timely inspections and communications between the contractor and/or owner and FAS inspectors and field staff.

A structural inspection request questionnaire will not be required when a roof change out occurs if no structural changes are made in the roof sub-surface and roof cavity. Example: Repairing or replacing the roof trusses, rafters, ridge beam and the replacement of not more than (4) 4’x 8’ of roof sheathing.

 Form
 F622-076-000
Safety and Health Discriminaiton Complaint - (Spanish) Queja de Discriminación de la División de Seguridad Y Salud Ocupacional

Si Usted piensa que ha sido discriminado o despedido por reportar los peligros existentes en su lugar de trabajo, utilice este formulario para presentar una queja.

 Form
 F416-011-999
Safety and Health Discrimination Complaint

Use this form to file a complaint when you feel you''ve been discriminated against or discharged for reporting a workplace safety hazard.

 Form
 F416-011-000
Safety and Health Discrimination in the Workplace (English/Spanish)/ Discriminación de seguridad y salud en el lugar de trabajo

Poster: Employees have the right to report concerns about safety and health in their workplace. This poster describes "protected activities" under the Washington Industrial Safety and Health Act (WISHA) and explains what an employee should do if he/she has been punished or fired for exercising these rights. Get poster printing tips.

 Poster
 F417-188-909
Safety and Health Discrimination in the Workplace

Brochure: Employees have the right to report concerns about safety and health in their workplace. This brochure describes "protected activities" under the Washington Industrial Safety and Health Act (WISHA) and explains what an employee should do if he/she has been punished or fired for exercising these rights.

 Publication
 F417-244-000
Safety and Health Investment Projects (SHIP) Grant Program

Booklet: Introduces the SHIP Grant Program and application process. SHIP awards grants for innovative projects that (1) prevent workplace injuries, illnesses and deaths and (2) encourage injured workers to return to work early and reduce long-term disability.

 Publication
 F417-224-000
Safety and Health Program Assessment Worksheet

Safety and Health Program Assessment Worksheet

 Form
 F417-227-000
Safety and Health Workshops

Pamphlet/Brochure: Introduces free workshops to help employers prevent workplace injuries and control workers'' compensation costs. Includes course descriptions, and how to register.

 Publication
 F416-036-000
Safety Meeting Minutes - Spanish - Actas De La Reúnion de Seguridad

Use este formulario para registrar las actas de sus reuniones de seguridad, estos registros deben mantenerse por un año a partir de la fecha de cada reunión.

 Form
 F417-087-999
Safety Meeting Minutes

Use this form to record the minutes from your safety meetings - these records must be retained for one year from the date of each meeting

 Form
 F417-087-000
Safety Standards for Administrative Rules WAC 296-900

Administrative Rules and the DOSH Administrative Manual affords employers the right to administrative and judicial review of alleged violations, initial penalties and abatement periods.

 Manual
 F414-136-000
Safety Standards for Confined Spaces WAC 296-809

This chapter applies to all confined spaces and provides requirements to protect employees from the hazards of entering and working in confined spaces.

 Manual
 F414-068-000
Safety Standards for Construction Work WAC 296-155

Construction work shall mean and include all or any part of excavation, construction, erection, alteration, repair, demolition, and dismantling, of buildings and other structures.

 Manual
 F414-033-000
Safety Standards for Core Rules WAC 296-800

The Core rules contains basic safety and health rules that affect all employers and should cover almost everything small, nonmanufacturing employers need for a safe and healthful workplace.

 Manual
 F414-059-000
Safety Standards for Ethylene Oxide WAC 296-855

Ethylene Oxide is a flammable colorless gas that is commonly used to sterilize medical equipment and as a fumigant for certain agricultural products. It is also used as an intermediary in the production of various chemicals such as ethylene glycol, automotive antifreeze, and polyethylene. Exposure is the contact an employee has with ethylene oxide, whether or not protection is provided by respirators or other personal protective equipment (PPE). Exposure can occur through various routes of entry such as inhalation, ingestion, skin contact, or skin absorption.

 

 Manual
 F414-132-000
Safety Standards for Fire Fighters WAC 296-305

The rules of this chapter shall apply with respect to any and all activities, operations and equipment of employers and employees involved in providing fire protection services, fire fighters and their work places, including the fire combat scene.

Firefighters are rescuers extensively trained in firefighting, primarily to extinguish hazardous fires that threaten property and civilian or natural populations and to rescue people from dangerous situations, like collapsed or burning buildings.

 Manual
 F414-036-000
Safety Standards for Forklifts and Other Powered Industrial Trucks WAC 296-863

This chapter applies to powered industrial trucks, electric motors or internal combustion engines, fork trucks, forklifts, tractors, platform lift trucks, motorized hand trucks and other specialized industrial trucks.

 Manual
 F414-126-000
Safety Standards for Ladders, Portable and Fixed WAC 296-876

This chapter applies to portable and fixed ladders, including job-made wooden ladders, ladder safety, the proper construction, use, placement, and care in handling ladders.

 Manual
 F414-133-000
Safety Standards for Laundry Machinery and Operations WAC 296-303

Laundry Machinery and Operations applies to moving parts of equipment used in laundries and to conditions peculiar to this industry, with special reference to the point of operation of laundry machines in an establishment wherein the washing, ironing, or other finishing of clothes, or any other textiles is done.

 Manual
 F414-012-000
Safety Standards for Logging Operations WAC 296-54

This chapter establishes safety practices for all types of logging, log road construction and other forest activities using logging machinery and/or power saws regardless of the end use of the wood. This includes; logging, cutting and transporting timber, cutting timber, log harvesting logging, pulpwood logging camps, rails, rough wood, manufacturing, stump removing in the field, timber piling, timber pole cutting, tree chipping in the field, wood chipping in the field. In addition, logging and personal protective equipment, hand and portable powered tools, falling and bucking, tree pulling, mechanized falling, climbing equipment, rigging, spars, wire rope and various types of cable logging systems, guylines, tail/lift trees and anchors, yarding, skidding, landing, transportation of logs and stationary trailer loaders, log unloading, booms, and rafting grounds, transportation crews, signals and signal systems.

 Manual
 F414-016-000
Safety Standards for Possession, Handling, and Use of Explosives WAC 296-52

Explosives mean any chemical compound or mechanical mixture commonly intended or used for the purpose of producing an explosion.

 Manual
 F414-038-000
Safety Standards for Railroad Clearances and Walkways in Private Rail Yards and Plants WAC 296-860

This chapter applies to all railroad clearances and walkways in rail yards and plants including logging railroad yards such as mill yards, maintenance yards and sorting yards.

To prevent injuries and fatalities to employees by maintaining safe railroad clearances and walkways in your rail yards and plants.

 Manual
 F414-113-000
Safety Standards for Shipbuilding, Ship Repairing and Shipbreaking Chapter 296-304 WAC

Safety Standards for Shipbuilding, Ship Repairing and Shipbreaking Chapter 296-304 WAC

 Manual
 F414-025-000
Safety Standards for WAC 296-115, Charter Boats

Rules for charter boats not covered by the United States Coast Guard

 Manual
 F414-050-000
Safety Standards for WAC 296-24 - General Safety and Health

The rules in this chapter are designed to protect the safety and health of employees by creating a healthy work environment by establishing requirements to control safety hazards in the workplace.

 Manual
 F414-040-000
Safety Standards for WAC 296-32, Telecommunications

Rules for employees working with telecommunication systems

 Manual
 F414-017-000
Safety Standards for WAC 296-45  -  Electrical Workers

Safety Standards for Electrical Workers, 296-45 WAC, consist of the requirements for safeguarding employees against electrical hazards in their workplace; requirements for electric equipment and wiring in locations classified as hazardous.

 Manual
 F414-032-000
Safety Standards for WAC 296-59, Ski Area Facilities & Operations

Rules for ski areas

 Manual
 F414-048-000
Safety Standards for WAC 296-62, General Occup Health

The rules in this chapter are designed to protect the health of employees and help to create a healthy workplace by establishing requirements to control health hazards. Requirements for chemical hazard communication programs, workplace lighting levels and exposure records are in chapter 296-800 WAC, the safety and health core rules.

 Manual
 F414-042-000
Safety Standards for WAC 296-67 - Process Safety Management of Highly Hazardous Chemicals

The purpose this of section, Chapter 296-67 WAC, Process safety management of highly hazardous chemicals, contains requirements for preventing or minimizing the consequences of catastrophic releases of toxic, reactive, flammable, or explosive chemicals. These releases may result in toxic, fire, or explosion hazards.

 Manual
 F414-090-000
Safety Standards for WAC 296-802, Employee Medical and Exposure Record

The purpose of this chapter is to provide employees and their designated representatives the right to access relevant medical and exposure records. It also describes the procedures WISHA will follow when accessing confidential medical information.

 Manual
 F414-122-000
Safety Standards for WAC 296-811, Fire Brigades

Applies to any workplace that chooses to establish a fire brigade.

 Manual
 F414-134-000
Safety Standards for WAC 296-829, Helicopters Used as Lifting Machines

Chapter 296-829 WAC applies to helicopters when used to carry loads, suspended with a cargo sling, powered hoist, or other attaching methods.

 Manual
 F414-121-000
Safety Standards for WAC 296-832, Late Night Retail

Crime protection requirements for a retail establishment operating between 11pm and 6am. (Does not include restaurants, hotels, taverns, or any lodging facilities)

 Manual
 F414-112-000
Safety Standards for WAC 296-835, Dip Tanks

The requirements for guarding against the hazards of dip tanks.

 Manual
 F414-109-000
Safety Standards for WAC 296-841, Airborne Contaminants

Applies to any workplace with potential or actual employee exposure to respiratory hazards

 Manual
 F414-118-000
Safety Standards for WAC 296-843, Hazardous Waste Operations

Rules for hazardous waste sites and operations.

 Manual
 F414-120-000
Safety Standards for WAC 296-848, Arsenic

This chapter applies to all occupational exposure to inorganic arsenic.

 Manual
 F414-130-000
Safety Standards for WAC 296-849, Benzene

This chapter applies to all occupational exposure to benzene.

 Manual
 F414-129-000
Safety Standards for WAC 296-856 Formaldehyde

Applies to all occupational exposure to formaldehyde. Formaldehyde includes formaldehyde gas, its solutions, and materials that release formaldehyde.

 Manual
 F414-143-000
Safety Standards for WAC 296-878, Window Cleaning

Safe window cleaning requirements.

 Manual
 F414-114-000
Safety Standards for WAC 296-901 - Global Harmonized System for Hazard Communication

Chapter 296-901 WAC, GHS is the Globally Harmonized System of Classification and Labeling of Chemicals. The GHS is a system for standardizing and harmonizing the classification and labeling of chemicals.

 Manual
 F414-155-000
Safety Standards for WAC 296-78- Sawmillis & Woodworking Operations

The Department of Labor and Industries has rewritten and reorganized for clarity and ease of use, Chapter 296-78 WAC, Sawmills and Woodworking Operations.

 Manual
 F414-010-000
Safety Standards for WAC 296-842  - Respirators

An apparatus worn over the mouth and nose or the entire face to prevent the inhalation of dust, smoke, or other noxious substances. Respirator is a type of personal protective equipment designed to protect the wearer from airborne contaminants, oxygen deficiency, or both.

 Manual
 F414-119-000
Safety Standards Lockout/Tagout WAC 296-803

Lockout/Tagout applies to the service and maintenance of machines and equipment, including piping systems, if employees could be injured by the unexpected energization or start up of the machine or equipment or release of stored energy. Energy sources include mechanical, hydraulic, pneumatic, chemical, thermal, or other energy, including gravity. Machines and equipment include those that produce high intensity electromagnetic fields.

 Manual
 F414-124-000
Safety Standards Machine Safety WAC 296-806

This chapter applies if you have machines or machine operations in your workplace. Machines and their moving parts create the potential for workplace injuries.

 Manual
 F414-125-000
Safety Standsards for WAC 296-874 - Scaffolds

Scaffolds, Chapter 296-874 WAC, applies to suspended and supported scaffolds, including their supporting structure and anchorage points. A scaffold is a temporary elevated platform, including its supporting structure and anchorage points, used for supporting employees or materials. A suspended scaffold is one or more platforms suspended from an overhead structure by ropes or other non-rigid means.

 Manual
 F414-128-000
Sample Format for Vocational Evaluation Testing Plan

Used by vocational counselors to evaluate the testing plan of the injuried worker.

 Form
 F252-052-000
Sample Format for Vocational Testing Report

Used by vocational counselors to test an injuried worker''s skills and abilities.

 Form
 F252-051-000
Sample Self-Employment Agreement

Sample of a letter a return to work person would use to assist L&I in determining whether services or funds should be authorized to assist them in becoming self-employed.

 Form
 F252-032-000
Schedule of Future Payments for the Balance of the Permanent Partial Disability Award

Schedule of Future Payments for the Balance of the Permanent Partial Disability Award.

 Form
 F207-162-000
Se ha lesionado en el trabajo?

Tarjeta para billetera:  Explica cómo presentar un reclamo de compensación para los trabajadores por teléfono.

 Publication
 F242-404-999
Seasonal Group Variance Application

Used for Exceptions from the Hours of Work for Minors for Seasonal work.  Complete the form, print it, sign it and fax or mail it to the address at the top of the form. Variance Application forms may be faxed to (360) 902-5300. If you would like the approved Variance Certificate faxed back to your business, please state so on your cover sheet.

 Form
 F700-135-000
Seguridad con los tractores: Protección contra vuelcos y los cinturones de seguridad

Panfleto/folleto: Resumen de las reglas de seguridad para la Barra Protectora contra Vuelcos (ROPS, por su sigla en inglés) y los cinturones de seguridad en los tractores. También lista las exenciones y proporciona otra información sobre la operación segura de tractores.

 Publication
 F417-234-999
Self Insurance Continuing Education Report of Course Completion

Used by department-approved claims administrators to report course completion for obtaining continuing education credit.

 Form
 F207-191-000
Self Insurance Continuing Education Sponsor/Instructor Application for Course Approval

Used by sponsors or instructors of continuing education courses, when requesting the department assign credit to a course so that department-approved claims administrators who attend can earn credit toward recertification under the Self Insurance Continuing Education program.

 Form
 F207-192-000
Self-Insurance Certification Questionnaire

Used by employers applying to become self-insured to describe their proposed workers'' compensation program.

 Form
 F207-176-000
Self-Insurance Continuing Education Application for Course Approval and Attendance

Used by Certified Claims Administrators to apply for continuing education credits for a course attended that has not been approved for credits.

 Form
 F207-206-000
Self-Insurance Electronic Data Reporting System (SIEDRS): Enrollment Package 2.0

Book: Explains the technical requirements for participating in SIEDRS, the Self-Insurance Electronic Data Reporting System.

 Publication
 F207-194-000
Self-Insurance Medical Provider Billing Dispute form

A form for Providers to submit disputes to the department regarding payment of medical provider bills

 Form
 F207-207-000
Self-Insurance Report of Occupational Injury or Disease (SIF-5)

Used by only self-insured employers or their representatives to report initial time loss payments or to request interlocutory, wage, overpayment or closure orders.

 Form
 F207-005-000
Self-Insurance Vocational Reporting Form

Used by self-insured employers and their representatives to report to L&I an injured worker''s eligibility for vocational services or ability to work. This replaces F207-121-000 Employability Assessment Report (EAR).

 Form
 F207-190-000
Self-Insured Employer Certificate of Excess Insurance

Used to provide excess insurance for a self-insurance program.

 Form
 F207-095-000
Self-Insured Employers'' Medical Only Claim Closure Order and Notice

Used by self-insured employers or their representatives, this is legal notification to an injured worker that their claim is being closed with medical benefits only. This order is used only when neither time loss compensation nor a permanent partial disability award has been paid.

 Form
 F207-020-111
Self-Insured Employers'' Permanent Partial Disability Closure Order and Notice - PPD-NTL

Used by self-insured employers or their representatives only, this is legal notification to an injured worker that their claim is being closed. This order is used only when time loss compensation has not been paid, but a permanent partial disability award is being paid.

 Form
 F207-165-000
Self-Insured Employers'' Permanent Partial Disability Closure Order and Notice - PPD-TL

Used by self-insured employers or their representatives only, this is legal notification to an injured worker that their claim is being closed. This order is used only when time loss compensation has been paid, and a permanent partial disability award is also being paid.

 Form
 F207-164-000
Self-Insured Employers'' Time Loss Claim Closure Order and Notice

Used by only self-insured employers or their representatives, this is legal notification to an injured worker that their claim is being closed. This order is used only when time loss compensation has been paid, but no permanent partial disability award is being paid.

 Form
 F207-070-000
Self-Insurer Accident Report (SIF-2)

Provided to workers by the self-insured businesses or their third party claims administrators to report an industrial injury or occupational disease. This form is not on the internet. If you are an injured worker, ask your employer for a copy of this form. Self-insured businesses or their third party claims administrators may order copies of this form. Cllick the "order It" button below to order paper copies or request the form in MSWord.

 Form
 F207-002-000
Self-Insurer''s Pension Bond

Used by self-insured employers as an option to provide collateral for a permanent total disability claim.

 Form
 F207-065-000
Servicios de Intérprete para Trabajadores Lesionados y Víctimas de Crimen

Volante: Describe los servicios de intérprete disponible a los trabajadores lesionados y a las víctimas de crimen.  Incluye información de cómo obtener un intérprete; quién puede interpretar y recibir pago; y el concepto básico de conducta profesional del intérprete.

 Publication
 F245-412-999
Settling your injured worker''s L&I claim: A new option for injured workers over 55

Pamphlet/booklet: Explains structured settlement and provides an overview of eligibility and the application and approval processes. The audience for this pamphlet is employers covered by the state''s workers'' compensation program. Self-insured employers should read Publication F240-005-000.

 Publication
 F240-004-000
Settling your L&I claim might be right for you: A new option for injured workers over 55

Pamphlet/booklet: Explains structured settlement and provides an overview of eligibility and the application and approval processes. The audience for this pamphlet is injured workers who might be eligible.

 Publication
 F240-003-000
Si usted TIENE que remover este resguardo 5 1/2 x 2 1/8

Etiqueta adhesiva: 5.5 pulgadas x 2.15 pulgadas

 Sticker
 FSP0-993-991
Si usted TIENE que remover este resguardo 8.5 x 5.5

Etiqueta adhesiva: 8.5 pulgadas x 3.5 pulgadas

 Sticker
 FSP0-993-999
SIEDRS (Self-Insurance Electronic Data Reporting System) Data Change Request

This is a data change request form. F207-193-000 is the Self-Insurance Electronic Data Reporting System (SIEDRS) Enrollment Form

 Form
 F207-197-000
SIF-5A Cover Sheet: Wage Calculations

Used by only self-insured employers and their representatives to calculate and report injured workers’ wages and time loss compensation rates.

 Form
 F207-156-000
Solicitud de Cuenta para Proveedores Fuera del País

Esta solicitud es para proveedores fuera de los Estados Unidos.  Los proveedores que brindan tratamiento a los trabajadores lesionados deben tener un número de proveedor para poder cobrarle al Departamento.

 Form
 F248-361-999
Sports Player Coverage Agreement

Used by a sports team or league and professional athlete (player) to declare that the player''s work is principally localized in another state in accordance to the provisions of RCW 51.12.120 and WAC 296-17-32503.

 Form
 F212-242-000
Sports Teams and Youth Workers

Fact sheet: Explains the requirements for sports organizations that engage young people as volunteers or employees to referee, assist or work for the organizations. The focus is workers'' compensation coverage and minor work rules.

 Publication
 F700-130-000
Sports Teams Coverage Agreement

Used by a sports team or league covering their Washington players through an out-of-state workers'' compensation insurance carrier to confirm compliance with RCW 51.12.120 and WAC 296-17-32503.

 Form
 F212-196-000
Standard Hand Signals for Cranes

Poster: Displays proper hand signals for directing crawler, locomotive and truck crane operators. Please order from L&I or print on 11" X 17" paper.

 Poster
 FSP0-910-000
Statement for Compound Prescription

Bill form for use by pharmacies and home infusion companies to submit compound drug charges. This form is for drug charges only and is filled out by the pharmacist.

 Form
 F245-010-000
Statement for Crime Victim Miscellaneous Services

Used by the provider or supplier for reimbursement of the following services - dental, glasses, home health, nursing home serivces, medical equipment, prosthetics-orthotics, transportation, vocational, retraining and other.

 Form
 F800-076-000
Statement for Crime Victims Mental Health Services

Used by the Crime Victims Compensation Program providers for reimbursement of Mental Health Services.

 Form
 F800-025-000
Statement for Home Nursing Services

Used to bill L&I for reimbursement of home nursing services.

 Form
 F248-160-000
Statement for Miscellaneous Services

This bill form is used by providers and injured workers to bill the department for services such as dental care; glasses; medical equipment; nursing home services; interpreter services; services workers pay for out of pocket; and other services. Information on how to bill the department can be found in the General Provider Billing Manual [F248-100-000].

 

 Form
 F245-072-000
Statement for Pharmacy Services

Bill form for prescription charges. May be used by a pharmacy to submit drug charges, or by a worker to request reimbursement for prescriptions paid out of pocket. See the General Provider Billing Manual (F248-100-000) for information on completing this form.

 Form
 F245-100-000
Statement for Retraining and Job Modification Services

Bill form for providers that bill the department for claim-related retraining and job modification services. See the General Provider Billing Manual (248-100-000) for information on completing this form.

 Form
 F245-030-000
Statement of Intent to Pay Prevailing Wages - Public Works Contract

This form is a fillable Word document that is used by a contractor, company or agency upon accepting work on a public works project. The best way to use this use this document is to bookmark this page as a “Favorite” in your web browser. Then each time when you want to use the document, access the online version of the form. This will ensure you are always utilizing the most recently published form. (We recommend you not download the document and save it for future use because we may make changes to the form that your downloaded version will not contain.) You should file this form immediately after the contract is awarded and before you begin work. Form number F700-160-000 is addendum A and F700-163-000 is addendum C.

 Form
 F700-029-000
Statement of Intent to Pay Prevailing Wages Addendum A

Please use this addendum to list additional Crafts/Trades/Occupations when you need to add more Crafts/Trades/Occupations than the Statement of Intent to Pay Prevailing Wages form can accommodate. Addendum A is for form F700-029-000.

 Form
 F700-160-000
Statement of Intent to Pay Prevailing Wages Addendum C

Please use this addendum to provide any additional information you want to communicate to L&I when you file a Statement of Intent to Pay Prevailing Wages. Addendum C is for form F700-029-000.

 Form
 F700-163-000
Statement

This form is predominately used in non-accident related types of inspections. Used to obtain statements from employees or other individuals whenever it is determined that it would be useful to adequately document an apparent violation.

 Form
 F416-016-000
Statewide Payee Registration and W-9 Form Crime Victims

Used by a provider assisting victims of crime to obtain a taxpayer ID number. Note: Register now for direct deposit available January 2013.

 Form
 F800-065-000
Statewide Payee Registration and W-9 Form

Use this form to register or update your taxpayer ID number or register and make changes to your direct deposit information.

 Form
 F248-036-000
Stay at Work Expense Reimbursement Application for Employers Tools, Clothing, Training.

Employer of record can request reimbursement for tools, clothing, or training expenses required to enable an injured worker to return to light duty or transitional work. After completing the form, the employer submits it, along with supporting documentation, to the Stay at Work program for review and approval. For wage reimbursements see F243-001-000.

 Form
 F243-003-000
Stay at Work Wage Reimbursement Application for Employers

Employer of record can request reimbursement for wages paid to an injured worker during light duty or transitional work. After completing the form, the employer submits it, along with supporting documentation, to the Stay at Work program for review and approval. For expense reimbursements see F243-003-000.

 Form
 F243-001-000
Stay at Work: A new program to help employers keep injured workers on the job--pays half the wage plus expenses

Pamphlet/booklet: Provides an overview Stay at Work, a financial incentive program that encourages Washington employers to find light-duty or transitional jobs for workers recovering from on-the-job injuries. Includes information on eligibility, how to apply, and where to get more information.

 Publication
 F243-006-000
Steel or Wrought-Iron Gas Line Pre-Inspection Checklist

This checklist is used by the contractor when installing steel or wrought-iron gas line. Be sure you can answer YES to all questions before calling L&I for an inspection.

 Form
 F622-044-000
Sticker - Danger! Minimum Clearance - Logging

Sticker size = 8.25 x 6.

 Sticker
 FSP0-972-000
Structural Inspection Request Questionnaire

Structural Inspection Request Questionnaire

 Form
 F622-075-000
Structured Settlement Income and Expense Worksheet

This form is completed by the injured worker, or their representative in conjunction with an Application for Structured Settlement.

 Form
 F240-007-000
Student Learner Variance Application

Employer uses this application form for requesting a variance to employment regulations for minors enrolled in a work-based learning placement. It can be used for individual or multiple minors for the same employer.

 Form
 F700-166-000
Student Volunteers and Workers'' Compensation Coverage

Fact sheet: Covers availability, limitations and cost of Washington State''s optional workers'' compensation coverage for student volunteers.

 Publication
 F213-023-000
Su cuerpo, su empleo: Prevención del Síndrome del Túnel Carpiano yotros trastornos músculo esqueléticos de las extremidades superiores

Panfleto/folleto:  Indica los síntomas y factores de riesgo para el síndrome del túnel carpiano y otros transtornos músculo esqueléticos que afectan el hombro, brazo y codo.  Discute los enfoques de prevención y dónde pueden encontrar más información.  

 Publication
 F413-024-999
Su Examen Médico Independiente: Para empleadores de negocios autoasegurados

Panfleto: Contesta las preguntas más comunes sobre cuándo y por qué puede requerirse que un trabajador lesionado asista a un examen médico independiente.  Incluye el formulario, "Examen Médico Independiente (IME) Solicitud para el reembolso de gastos de viaje y salario." Esta publicación es para uso solamente de las empresas autoaseguradas y sus trabajadores.

 Publication
 F207-202-999
Su Examen Médico Independiente

Panfleto/folleto: Respuestas a las preguntas más comunes sobre los exámenes médicos independientes y cuándo y por qué podría requerirse que un trabajador lesionado asistiera a uno.  Incluye el formulario “Examen Médico Independiente (IME) - Solicitud para el reembolso de gastos de viaje y salario.” Este formulario es solamente para el uso de negocios autoasegurados y sus trabajadores.

 Form
 F245-224-999
Su Examen Médico Independiente

Panfleto/folleto: Respuestas a las preguntas más comunes sobre los exámenes médicos independientes y cuándo y por qué podría requerirse que un trabajador lesionado asistiera a uno.  Incluye el formulario “Examen Médico Independiente (IME) - Solicitud para el reembolso de gastos de viaje y salario.” Este formulario es solamente para el uso de negocios autoasegurados y sus trabajadores.

 Publication
 F245-224-999
Subacute Opioid Request Form

Use this form to request opioid coverage between 6 weeks to 12 weeks from the date of injury or surgery.

 Form
 F252-097-000
Submission of Provider Credentials for Interpretive Services

Used to apply as a interpretive service provider and to show what language(s) you hold credentials for. F248-011-000 Provider Application and Notice is added to this form.

 Form
 F245-055-000
Subscription Request for Construction Contractor and Electrical Basic - CD

This form is to be used to purchase the CD ROM of registered construction contractors, registered electrical contractors, plumbers and electricians.

 Form
 F625-051-000
Summary of Agricultural Employment Regulations and Farm Contractor Requirements

This summary is on employment laws relating to the agricultural industry.

 Publication
 F700-124-000
Supervisor''s Report of an Accident

Supervisors use this form to document information from an accident or injury.

 Form
 F417-048-000
Supplemental Quarterly Report for the Drywall Industry

Used by drywall companies to file their quarterly report. Must accompany the Drywall Industry Owner/Sub-Contractor Report (F212-050-000).

 Form
 F212-051-000
Sus Pulmones Su trabajo Su vida: Lo que debería saber acerca del asma ocupacional

Panfleto/folleto:  Brevemente indica los síntomas y las causas del asma relacionada con el trabajo  y explica  la prevención y enfoques de tratamiento.

 Publication
 F413-060-999
Teens at Work: Facts for Employers, Parents and Teens

Pamphlet/booklet: Answers questions employers, parents and teens may have about employing teen workers (ages 14-17). Explains non-agriculture work rules, including the necessary permits, hours and work conditions. Provides links to other resources.

 Publication
 F700-022-000
Temporary Licensed Elevator Mechanic

This temporary license is limited to the mechanical and electrical operation, construction, installation, alteration, maintenance, inspection, relocation and repair of conveyances.

 Form
 F621-068-000
Temporary Services Guide to Workers'' Compensation Insurance

Used by L&I to assign industrial insurance classifications for workers of temporary help agencies. The first file is a PDF of the Temporary Services Guide to Workers'' Compensation Insurance. The second file is a 2003 Excel file. This file is a cross match of non temporary help classifications and the temporary help risk classification associated with that risk class. The third file is a 2003 Excel file. This is a reverse look up for temporary help risk classification and the non temporary classes associated with a temporary help class. File contains an instructions worksheet for the reverse look up worksheet.

 Manual
 F213-019-000
Test of Escalator Safety Devices

A licensed elevator mechanic shall perform this test once a year and mail a copy to L&I.

 Form
 F621-055-000
The DOSH Consultation Manual

The DOSH Consultation Manual provides guidance regarding some of the internal operations of L&I and the Division of Occupational Safety and Health (DOSH). The contents of the manuals are not enforceable by any person or entity against the Department of Labor and Industries or the State of Washington.

 Manual
 F414-151-000
Third Party Recovery Worksheet

Used by third party attorneys to calculate distribution of proposed settlements in third party claims.

 Form
 F249-006-111
Tractor Safety: Rollover Protection and Seatbelts

Pamphlet: Summarizes the safety rules for rollover protective structures (ROPS) and seatbelts on tractors. Also lists exemptions and provides other information about safe operation of tractors.

 Publication
 F417-234-000
Training Agent Agreement and Understanding of Equal Employment Opportunity (EEO) Requirements of the Apprenticeship Committee - Alternate Selection Process

This should be signed by all employers who are Training Agents with Apprenticeship Programs that use an Alternate Selection Process. This also explains their obligations and rights as part of this process.

 Form
 F100-523-000
Training Plan Cost Encumbrance

To record the training costs. For use only with plans approved after 1/1/2008.

 Form
 F245-374-000
Transfer of Attending Provider Form for Self Insured Workers Spanish Formulario para Trasferencia de Proveedor Principal para Trabajadores Autoasegurados

Este formulario es utilizado por los trabajadores autoasegurados que desean transferir su cuidado médico. Los trabajadores autoasegurados deben completar este formulario y enviarlo a su empleador o a su Representante de Terceros.

 Form
 F207-114-999
Transfer of Attending Provider Form for Self Insured Workers

This form is used by self-insured injured workers who want to transfer their medical care.  Self-insured workers should complete the form and send it to their employer or their Third Party Representative.

 Form
 F207-114-000
Transfer of Care Card (Spanish) Tarjeta para Transferencia de Caso

Usada por los trabajadores lesionados para notificar al gerente de reclamo y solicitar autorización para transferir el cuidado a un doctor diferente.

 Form
 F245-037-999
Transfer of Care Card

Used by injured worker to notify claim manager and request authorization to transfer care to a different doctor. Do it online! Use the online Transfer of Care

 Form
 F245-037-000
Transportation Cost Encumbrance

To record the costs for transportation. For use only with plans approved after 1/1/2008.

 Form
 F245-375-000
Travel Reimbursement Request - (Spanish) Solicitud para el Reembolso de Gastos de Viaje

Los trabajadores lesionados usan este formulario para solicitar reembolso de los gastos de viaje usados para recibir tratamiento, capacitación y/o servicios vocacionales.

 Form
 F245-145-999
Travel Reimbursement Request - Crime Victims

If you are considered a victim of crime, use this form to track your travel expenses for medical, retraining or vocational services or for an independent medical exam. You should have approval from your claim manager before you travel.

 Form
 F800-049-000
Travel Reimbursement Request

Bill form for use by workers to request reimbursement for authorized travel expenses.

 Form
 F245-145-000
UB04 HCFA 1450

Used by hospitals to bill L&I for inpatient/outpatient services. This version includes NPI number.

 Form
 F245-367-000
Una Guía de Seguridad y Salud del Lugar de Trabajo en el Estado de Washington

Panfleto/folleto: Provee un resumen de la Ley de Seguridad y Salud Industrial de Washington (WISHA, por su sigla en inglés), derechos y responsabilidades del trabajador y del empleador, cumplimiento de las leyes de WISHA y los servicios de consultoría y educación que L&I proporciona. El título anterior era, Una Guía de WISHA.

 Publication
 F416-132-999
Unpaid Internships 101

Fact sheet: Document provides information as the state and federal restrictions for unpaid interns who are in an educational capacity in a workplace.

 Publication
 F700-173-000
Upgrade from Specialty Contractor to General Contractor

Used to apply for an upgrade from Specialty Contractor to a General (01) Contractor.

 Form
 F625-113-000
Variance Application - Employment Standards

Employer application request for a variance from employment standards for non minor employees.

 Form
 F700-089-000
Variance Application - For exceptions from specific rules governing employment of minors.

Employer uses this application for requesting a variance to employment regulations for minors.

 Form
 F700-076-000
Variance Application - IND S&H

Use this form to apply for a variance for an allowed deviation from a specific safety or health standard when an employer substitutes measures which afford an equal degree of safety.

 Form
 F414-021-000
Vendor / Medical Conversion Units Pre-Inspection Checklist

Pre-Inspection Checklist to assist vendor owners, manufacturers, and others on what they need to know to get their vendor/medical unit approved by Labor and Industries.

 Form
 F622-072-000
Verification of School Enrollment/Verificación de registro en la escuela (Spanish)

Usada por un estudiante y un oficial de escuela cada trimestre para verificar el registro en la escuela.

 Form
 F242-055-999
Victim Verification Form

For use by crime victims requesting wage replacement compensation

 Form
 F800-110-000
Vocational Closing Report Routing Sheet

Routing slip that accompanies the Vocational Services Closing Cover Sheet (F252-028-000) which is used to close vocational services to an injured worker.

 Form
 F252-027-000
Vocational Providers Application and Notice

Used to obtain a vocational provider account number with L&I. This form includes a copy of F248-036-000 "Request for Taxpayer ID number and Certification". (12 pages) CURRENT EXISTING VOCATIONAL PROVIDER FIRMS THAT ARE ALREADY REGISTERED WITH L&I USE THIS FORM AND W-9.

 Form
 F252-017-000
Vocational Questionnaire/Work History - Spansih CUESTIONARIO VOCACIONAL/HISTORIA DE TRABAJO

Cuestionario vocacional/historia de trabajo para uso de los proveedores vocacionales que sirven a los trabajadores lesionados.

 Form
 F280-038-999
Vocational Questionnaire/Work History

Vocational Questionnaire/Work History for use by Vocational Providers serving injured workers.

 Form
 F280-038-000
Vocational Services Closing Cover Sheet

Used to close vocational services of an injured worker. This form is attached to Vocational Closing Report Routing Sheets F280-013-000, F280-014-000 or F252-027-000.

 Form
 F252-028-000
Vocational Training Plan Ownership Agreement for Tools and Equipment

Injured worker agrees to the ownership terms of the tools and/or equipment purchased as part of their training plan by L&I.

 Form
 F245-351-000
WAC 296-63 - Right to Know Fee Assessment

Rules for the department to assess and collect Right-to-Know fees.

 Manual
 F414-049-000
Wage Transcription and Computation Sheet

Employer uses this to show time worked and wages earned for an employee.

 Form
 F700-024-000
Wage-and-Hour Questions Employers Often Ask

Fact sheet: Provides answers to questions related to pay requirements, deductions from pay, hiring a teen worker, employee uniforms and access to personnel file. Includes contact information if an employer needs assistance with a specific situation.

 Publication
 F700-150-000
Waiver of Lien by Contractor, Subcontractor(s) and Supplier

This is a waiver of lien by a contractor or a subcontractor or supplier.

 Form
 F625-029-000
Washington Contractor''s License Bond Address Change Rider

Used by the bond company to change the address of the contractor''s business.

 Form
 F625-104-000
Washington Contractor''s License Bond Bond Amount Rider

Used by the bond company to amend the amount of the contractor''s bond.

 Form
 F625-102-000
Washington Contractor''s License Bond Date Change Rider

Used by the bond company to change the effective date of the contractor''s bond.

 Form
 F625-101-000
Washington Contractor''s License Bond Entity Change Rider

Used by the bond company to show a change in the business structure of a contractor''s business.

 Form
 F625-103-000
Washington Contractor''s License Bond License Number Change Rider

Used by the bond company to change the contractor''s business license number.

 Form
 F625-100-000
Washington Contractor''s License Bond Name Change Rider

Used by the bond company to change the name of the contractor''s business.

 Form
 F625-099-000
Washington Contractor''s License Bond Validation Rider

This rider is intended to be used in conjunction with a bond.

 Form
 F625-098-000
Washington Practitioner Application

Washington Practitioner Application

 Form
 F245-411-000
Washington State Deduction Laws

Deductions for current & terminated employees and employer liability for paying less than required.

 Form
 F700-097-000
Washington State OverTime Law

Covers compensation for employees in Washington State working overime.

 Publication
 F700-079-000
Washington State Prevailing Wage Law

Booklet: Contains the prevailing wage laws (RCWs) and rules (WACs) as well as plain language descriptions and contact information.

 Publication
 F700-032-000
Washington State Top 25 Hazardous Industries

Booklet: Provides a summary of occupational injury and illness data, including safety and health violations cited, by the top 25 hazardous industries for the five-year period 2006 to 2010.

 Publication
 F417-243-000
What Are Your Rights as a Worker? / ¿Cuáles son sus derechos como trabajador? (English/Spanish)

Fact sheet: Provides a brief overview of the worker rights administered by the Department of Labor and Industries. These include certain employment-related rights and rights pertaining to workplace safety and workers'' compensation benefits.

Hoja de información: Proporciona un resumen de los derechos de los trabajadores administrados por el Departamento de Labor e Industrias. Estos incluyen algunos derechos relacionados con el empleo y derechos con la seguridad en el lugar de trabajo y beneficios de compensación para los trabajadores. 

 Publication
 F101-061-909
What Are Your Rights when You Work for a Farm Labor Contractor? (English/Spanish) / ¿Cúales son sus derechos cuando trabaja para un contratista de trabajadores agrícolas?

Fact sheet: Provides an overview of rights workers have when they are employed by a farm labor contractor. Several topics are covered, including regular wages, workplace safety, and help if injured on the job.

 Publication
 F700-067-000
What to Do if You Want to File Suit Against Your Construction Contractor

Fact sheet: Provides consumers with general information about the process for filing suit, and describes L&I''s limited role in serving Summons & Complaint papers.

 Publication
 F625-088-000
What You Should Know About Hiring a Contractor, Remodeler, or Handyman

Pamphlet/booklet: Provides a checklist for consumers considering hiring a general or specialty construction contractor, reviews the permitting process, and suggests ways to avoid lien problems. Washington State law requires contractors to register with L&I.

 Publication
 F625-084-000
WISHA Occupational Exposure to Bloodborne Pathogens - Chapter 296-823 WAC

Pathogenic microorganisms that are present in human blood and can cause disease in humans.

 Manual
 F414-073-000
Witness Statement

Use this form only on accident investigations, fatalities and catastrophies. This form is used to obtain statements from the witness to the accident or personnel who did not witness the accident but have information regarding the incident.

 Form
 F416-093-000
Wood / Pellet Stove / Fireplace Pre-Inspection Checklist

This checklist is designed to be generic in content and may not include all requirements for your particular installation.

 Form
 F622-015-000
Worker Request for Union Dispatch Records

Worker Request for Union Dispatch Records

 Form
 F242-410-000
Worker Rights Complaint Form

This is the Worker Rights Complaint Form. Both the 12-2011 and 10-2010 versions are valid.

 Form
 F700-148-000
Worker Verification Form

Completed by the injured worker if they are unable to work due to a workplace injury AND their employer is not paying their full wages.

 

 Form
 F242-052-000
Worker Verification Form - Spanish Formulario de Verificación de Empleo

El trabajador lesionado debe completarlo si no puede trabajar debido a una lesión en el lugar de trabajo Y su empleador no le está pagando su salario completo.  

 Form
 F242-052-999
Workers'' Compensation Benefits: A Guide for Injured Workers

Pamphlet/booklet: For workers covered by L&I (the State Fund). Describes benefits if you have a work-related injury or illness and how to file a claim. Explains a worker''s rights and responsibilities under Washington State''s industrial insurance law. Note: Previously titled, Workers'' Guide to Industrial Insurance Benefits.

 Publication
 F242-104-000
Workers'' Compensation Employer''s Quarterly Report - SAMPLE ONLY

You must fill out this form quarterly even if you had no workers. These forms are mailed out quarterly to all employers. For instructions on how to complete the Quarterly Report, please refer to F212-239-000 which is available on the internet. This file on the internet is a sample only.

 Form
 F212-055-000
Workers'' Compensation Filing Information

Used by only self-insured employers to comply with WAC 296-15-400. The form provides information and instructions to employees of self-insured employers in case of an injury or development of an occupational disease.

 Form
 F207-155-000
Workers'' Compensation Insurance Manual

This manual covers Chapter 296-17 and 296-17A WAC. Topics covered are employer reporting requirements for workers'' compensation; employer classification for workers'' compensation; and rates and experience rating rules for workers'' compensation.

 Manual
 F213-178-000
Workers'' Compensation Record Keeping and Reporting Guides

Packet: Contains eight quick reference cards covering topics related to workers'' compensation record keeping and reporting. Topics include: computering worker hours, standard exception classifications, excluded employments and corporate officers.

 Publication
 F212-222-000
Workers'' Guide to Hazardous Chemicals / Gua del trabajador para el uso de qumicos (English/Spanish)

Brochure: Explains workers'' rights under Washington''s Hazard Communication rule but does not fulfill an employer''s legal obligation to provide information and training to employees.

Includes information for workers about working safety around hazardous chemicals and understanding warning labels.

The Spanish section of this publication is being revised and will be available in the future. / La sección en español de esta publicación está siendo revisada y estará disponible en el futuro.

 Publication
 F413-014-909
Workplace Safety and Health Pocket Guide

Pocket guide: Provides links to online information, including safety and health consultations, how to develop a safety program, reporting hazards and injuries, other safety training, and information for teen workers.

 Publication
 F417-241-000
Workplace Safety and Health Rules and Guides

This CD has been discontinued, but the safety and health rules and guides are available on the L&I website.

For more information, see the links in the "Websites" section below.

These links contain all workplace safety and health rules for Washington State and policies and related laws. Included are guides covering accident prevention programs (APP) and personal protective equipment (PPE).

 

 CD
 F414-074-034
Your Daily Record of Hours and Units Worked - For Agricultural Workers / Spanish - Su Registro Diario de Horas y Unidades Trabajadas - Para Trabajadores Agrícolas

Booklet: A pocket-sized bilingual guide to encourage agricultural workers to keep track of their daily work hours, units and earnings.

 Publication
 F700-169-909
Your Independent Medical Exam

Pamphlet/booklet: Answers the most common questions about independent medical exams and when and why an injured worker may be required to receive one. Includes the "IME Travel & Wage Reimbursement Request" form.

 Form
 F245-224-000
Your Independent Medical Exam

Pamphlet/booklet: Answers the most common questions about independent medical exams and when and why an injured worker may be required to receive one. Includes the "IME Travel & Wage Reimbursement Request" form.

 Publication
 F245-224-000
Your Lungs, Your Work, Your Life: What You Should Know about Work-related Asthma

Pamphlet/booklet: Briefly reviews the symptoms and causes of work-related asthma and explains prevention and treatment approaches.

 Publication
 F413-060-000
Your Manufactured/Mobile Home

Pamphlet/booklet: Covers things you should consider when altering your home. Defines what is meant by alteration, repair and replacement and includes tips for hiring a registered contractor. It also includes contact information for L&I Consumer Assistance Program for owners of new manufactured/mobile homes.

 Publication
 F622-049-000
Your Premium Dollars at Work (2011)

Pamphlet/booklet: Provides information about the programs and services financed with workers'' compensation premium dollars, along with statistics such as number of claims, demographics of claims and the most frequent types of injuries.

 Publication
 F200-019-000
Your Premium Dollars at Work (2012)

Pamphlet/booklet: Provides information about the programs and services financed with workers'' compensation premium dollars, along with statistics such as number of claims, demographics of claims and the most frequent types of injuries FY2012 (year ending June 30, 2012). Includes narrative about workers'' compensation reforms.

 Publication
 F200-020-000
Your Premium Dollars at Work (2013)

Pamphlet/booklet: Provides information about the programs and services financed with workers'' compensation premium dollars, along with statistics such as number of claims, demographics of claims and the most frequent types of injuries during FY2013 (year ending June 30, 2013). Includes narrative about workers'' compensation reforms.

 Publication
 F200-022-000
Your Rights as a Worker in Washington State/ Sus Derechos como Trabajador en el Estado de Washington (English/Spanish)

Required poster: Reviews workers'' rights under Washington''s wage-and-hour laws. Topics include minimum wage, overtime, meal and rest breaks, pay periods, deductions, and employment of teens under age 18. Also reviews family leave provisions under federal and state law, and leave for spouses of deploying military personnel and victims of domestic violence. Note: Employers in both agricultural and non-agricultural industries in Washington State must display this poster where workers can see it.

Please order from L&I or print on 11" x 17" paper.

Get poster printing tips.

 Poster
 F700-074-909
Your Rights as a Worker in Washington State/ Sus Derechos como Trabajador en el Estado de Washington (English/Spanish)

Required poster: Reviews workers'' rights under Washington''s wage-and-hour laws. Topics include minimum wage, overtime, meal and rest breaks, pay periods, deductions, and employment of teens under age 18. Also reviews family leave provisions under federal and state law, and leave for spouses of deploying military personnel and victims of domestic violence. Note: Employers in both agricultural and non-agricultural industries in Washington State must display this poster where workers can see it.

Please order from L&I or print on 11" x 17" paper.

Get poster printing tips.

 Publication
 F700-074-909
Your Workers'' Compensation Rate Notice - SAMPLE ONLY

Form used to compute Your Workers'' Compensation premiums. Page 2 has rate notice definitions. Sample only.

 Form
 F225-004-000
2006 Annual Report - Department of Labor & Industries
Provides a statistical overview of results achieved in fiscal year 2006 (July 1, 2005, through June 30, 2006), budget information and a narrative introduction to the Department of Labor & Industries.
 Publication
 F101-078-000
2014 Workplace Safety and Health Calendar: Top 12 Hazards that Cause Injuries and Deaths

Calendar: Features real Washington State businesses and employees handling typical workplace hazards and spotlighting the top 12 hazards that cause injuries and deaths. It includes suggested weekly safety and health tips for different hazards, including slips trips and falls, struck by falling objects, burns and more.

 Publication
 F417-248-000
A Parents'' Guide to Apprenticeships
Booklet: Designed specifically for parents, this booklet provides an overview of apprenticeship. Topics include the benefits of apprenticeship, career options, requirements, how to apply and contact information.
 Publication
 F100-530-000
A Safe and Healthy Workplace Begins with You
Pamphlet: Provides an overview of employers'' responsibilities for workplace safety and health in Washington State. Covers free L&I services, including workplace consultations, online training and prevention resources and required posters. Intended for new businesses or businesses hiring employees for the first time.
 Publication
 F417-210-000
Acknowledgement of Security Interest
Used to acknowledge that funds have been deposited into an account at a bank for the purpose of providing payment for the workers'' compensation benefits and assessments in the event of default by the self-insurer.
 Form
 F207-143-000
Address Change Request for Injured Workers
Completed and signed by a State Fund injured worker to notify L&I of a change in address. All address changes must be submitted in writing and signed by the injured worker.
 Form
 F242-388-000
Affidavit for Amusement Rides
Affidavit of experience to apply for cetification as a Amusement Ride Inspector.
 Form
 F500-066-000
Affidavit of Wages Paid EHB 2805 Addendum
F700-164-000 is an addendum to your Affidavit of Wages Paid Form. RCW 39.04.370 requires you to complete form F700-164-000 if the prime contract is at a cost of over one million dollars ($1,000,000). If you fail to properly provide the requested information more than one time between September 1, 2010 and December 31, 2013, pursuant to RCW 39.04.350(1)(f) you will not be considered a responsible bidder qualified to be awarded a public works project. Use as many of these forms as you need in order to provide the requested information for all relevant project items. This is an addendum to form F700-007-000.
 Form
 F700-164-000
Agency Requested Inspection
Used by non-L&I agencies and jurisdictional authorities to request an inspection on an electrical hazard.
 Form
 F500-025-000
Agricultural workers information line (English/Spanish)
Card: Wallet card with a toll-free telephone number where agricultural workers can call to learn about their workplace rights.
 Publication
 F700-103-909
Always Wear Eye Protection
Picture of a large eye with some content on when to use eye protection. Get poster printing tips.
 Poster
 FSP0-940-000
Application for Group Membership & Authorization for Release of Insurance Data
Used by employers who want to join a retrospective rating group; also, to authorize Labor & Industries to release the employers'' insurance data to the retrospective rating group they want to join.
 Form
 F250-016-000
Application for Inclusion on List of Eligible Attorneys
Used by attorneys to be included on the Workers'' Compensation Special Assistant Attorney General Program eligible list for Third Party claims.
 Form
 F249-017-000
Application to Access L&I''s Electrical Permit and Inspection System (EPIS) from SecureAccess Washington and Utilize Contractor Deposit Account via the Internet
To establish a contractor deposit account by an electrical contactor or registered construction contractors who are legally required to purchase electrical work permits from L&I.
 Form
 F500-055-000
Application to Establish an Account and Access to L&I''s Electrical Permit & Inspection System (EPIS) with L&I''s Miscellaneous Accounts
To request access to L&I''s EPIS - Miscellaneous Accounts
 Form
 F500-054-000
Applying for Your Washington Business License: A Step-by-Step Guide
Pamphlet: Concise, easy-to-read pamphlet that explains the steps to apply for a business license and what to do if you plan to employ workers. Includes how to apply to be a registered construction contractor.
 Publication
 F101-079-000
Apprentice Work Progress Record

Worksheets used to record the number of hours worked and Related Supplemental Instruction hours during a registered apprenticeship on a monthly basis. If used, a copy is usually given to the program monthly.

 Form
 F100-002-000
Apprenticeship Advantage poster
Poster: Introduces apprenticeship, especially for younger people. Promotes the benefits of apprenticeship and includes contact information to learn more.
 Poster
 F100-526-000
Apprenticeship Applicant Register
Example: Used for tracking applicants for an apprenticeship program. Registered Apprenticeship Programs use their own forms.
 Form
 F100-045-000
Apprenticeship Related Supplemental Instruction (RSI) Plan Revew Review Criteria
Describes the process for getting approval of new or revised RSI for new apprenticeship programs/standards/occupations.
 Form
 F100-521-000
Apprenticeship Related Supplemental Instruction (RSI) Plan Revew Review Criteria
Describes the process for getting approval of new or revised RSI for new apprenticeship programs/standards/occupations.
 Publication
 F100-521-000
Apprenticeship Related Supplemental Instruction (RSI) Plan Review Glossary of Terms
Glossary of terms used with Apprenticeship Related Supplemental Instruction (RSI) Plan Review form and RSI Plan.
 Form
 F100-519-000
Apprenticeship Related Supplemental Instruction (RSI) Plan Review Glossary of Terms
Glossary of terms used with Apprenticeship Related Supplemental Instruction (RSI) Plan Review form and RSI Plan.
 Publication
 F100-519-000
Approved Independent Medical Examiner (IME) Update
To update or correct the IME''s contact, availability, qualificaitons and/or exam sites.
 Form
 F245-051-000
Are You an Employer Who Can Provide On-the-Job Training?
Fact sheet: Explains how employers play an important role in helping injured or ill workers return to meaningful employment and a productive life by offering on-the-job training opportunities.
 Publication
 F280-033-000
ASC X12N 005010 EDI Transactions Companion Guide
Description: This guide details the HIPAA ASC X12N 005010 format structure for EDI and provides information regarding electronic billing To the department via Provider Express Billing (PEB)
 Manual
 F245-398-000
Assessing Your Ability to Work: Your Rights and Responsibilities
Booklet: Explains the basics of the assessment phase of vocational services to injured workers. L&I sends this booklet to injured workers when they are referred for assessment services.
 Publication
 F280-017-000
Assignment of Account Agreement
Used by a self-insured employer as an option to provide collateral for a total permanent disability claim.
 Form
 F207-058-000
Attending Provider''s Return-to-Work Desk Reference
Book: Discusses best practices in occupational medicine that help return an injured worker to his/her job as soon as medically possible. Identifies resources available from L&I and explains how to bill for return-to-work services. Three hours of Category 1 CME credit are offered for completing an online self-assessment. Go to www.CMECredits.Lni.wa.gov.
 Publication
 F200-002-000
Audit Reference Card
Quick reference card: Answers questions employers may have about audits L&I conducts to verify the that workers'' hours have been reported correctly and workers'' compensation premiums have been calculated accurately.
 Publication
 F214-020-000
Avoid Liability for Your Subcontractor''s Unpaid Workers'' Comp Premiums
Fact sheet: Tells construction contractors how to protect themselves from liability for their subcontractor''s unpaid workers'' compensation premiums.
 Publication
 F262-262-000
Before Electrical Sign Work Begins: What Electrical Sign Contractors and Electricians Should Know
Fact Sheet: Explains work that is allowed and not allowed under (04) Sign Scope of Work and what electrical sign contractors and electricians should know before doing sign work. Also covers electrical Class B labels and electrical permits, inspections and fees.
 Publication
 F500-111-000
Bicycle Safety: Delivery, couriers, and messengers

Fact Sheet: Provides a summary of requirements and tips to ensure the safety of bicycle couriers, bicycle messengers and bicycle delivery riders. Includes a safety checklist.

 Publication
 F417-250-000
Board of Boiler Rules Extension of Inspection Frequency Request Form
Board of Boiler Rules Extension of Inspection Frequency Request Form
 Form
 F620-055-000
Board of Boiler Rules Interpretation and Revision Request Form
Used to submit written requests for interpretations and revisions to the definitions, rules and regulations found in WAC 296-104. These must be submitted 45 days prior to the Board of Boiler Rules Meeting date. To use this form, left click on the link and select SAVE TARGET AS and save to your desktop. Open in WORD, complete form, select PRINT, SEND TO, MAIL or DELIVERY DOCUMENT ONLY in care of Chief, Boiler Inspector.
 Form
 F620-017-000
Board of Boiler Rules Washington State Specials Request Form
Board of Boiler Rules Washington State Specials Request Form
 Form
 F620-057-000
Boiler / Pressure Vessel Water Heater Installation or Reinstallation Permit
This form is filled out by the installer, contractor and/or owner who wants to install or reinstall a boiler.
 Form
 F620-032-000
Boiler/Pressure Vessel Clearance Variance Request
To request a clearance variance on a boiler or pressure vessel. You can only mail or fax this form to L&I. E-mailed forms are not accepted.
 Form
 F620-041-000
Carrying Out Your Vocational Plan: Your Rights and Responsibilities During Plan Implementation
Booklet: Explains the basics of the plan implementation phase of vocational services to injured workers. L&I sends this booklet to injured workers once the vocational plan they submitted is approved. Information about continuing with the vocational plan or selecting Option 2 to decline retraining is included.
 Publication
 F280-019-000
Caution: Hard Hat Area
Visual reminder of the importance of wearing a hard hat. Get poster printing tips.
 Poster
 FSP0-928-000
Challenging Times Demand Our Best
Booklet: Describes how L&I is making changes, both big and small, to better serve our customers and operate efficiently. Three areas of focus are fighting fraud, putting customers first and cutting costs. Features stories about three customers L&I has helped.
 Publication
 F101-095-000
Chief Inspector Clarification and Interpretation Request Form
Chief Inspector Clarification and Interpretation Request Form
 Form
 F620-056-000
Claim for Pension By Dependents
Used by dependents of a deceased worker to file a claim for benefits.
 Form
 F242-062-000
Claim for Pension by Spouse or Children
Used by a spouse or dependents of a deceased worker. The workers'' fatal accident or occupational disease incurred in the course of their employment. This application is needed to determine if applicant(s) is/are entitled to a survivor benefit.
 Form
 F242-056-000
CMS 1500 (formerly L&I Health Insurance Claim form)
Used by providers to be reimbursed for services. It is NOT for use by injured workers to submit a claim to L&I.
 Form
 F245-127-000
Comparing Career Pathways

Fact sheet: Assists high school students and their parents by comparing the benefits of registered apprenticeship to a traditional university or college program. Compares wages, costs, and length of study.

 Publication
 F100-531-000
Computing Worker Hours

Quick reference card: Shows employers how to figure workers'' compensation premiums for different types of employees: hourly employees, salaried employees, commissioned personnel or employees paid for piecework. This information is part of the publication, Workers’ Compensation Record Keeping and Report Guides.

 Publication
 F214-014-000
Congratulations! You''ve been approved to hire minors
Card: Reminds employers of special work rules for employees under age 18. Lists key points and provides a Web address for where to find more detailed information. Sent to all employers who obtain a minor work permit endorsement on the master business license.
 Publication
 F700-136-000
Construction Lien Summary

General requirements that a lien claimant of a private construction project (not a commercial) must meet. This is intended show the general requirements for most lien claimants.

 Form
 F625-055-000
Corporate Officers

Quick reference card: Explains the criteria to allow a corporate officer to be exempt from industrial insurance (workers'' compensation) coverage. This information is part of the publication, Workers’ Compensation Record Keeping and Report Guides.

 Publication
 F214-010-000
Crime Victims Compensation Program Initial Response and Assessment: Form I
Used by the clinical provider to get approval to see a victim for six sessions or less. If more than six sessions, please complete Form II (F800-081-000).
 Form
 F800-080-000
Crime Victims Direct Entry Billing Manual
Instructions for completing a Direct Entry bill to submit to the Crime Victims Compensation Program. Direct entry allows you to submit or adjust bills using a free online billing form through Provider Express Billing (PEB).
 Manual
 F800-118-000
Danger
Large lettering: DANGER. Get poster printing tips.
 Poster
 FSP1-030-000
Danger, Construction Area Authorized Personnel Only
Large words: Danger, Construction Area Authorized Personnel Only. Get poster printing tips.
 Poster
 FSP1-013-000
Danger, Workers Above
Picture of workers on a high rise. Get poster printing tips.
 Poster
 FSP1-012-000
Declaration of Entitlement for Dependent of Deceased Worker Benefits Under Industrial Insurance
Used by a dependent of a worker whose death was related to an on the job injury or accident. This form must be completed, signed, notarized and returned to L&I within 30 days for non interruption of benefits.
 Form
 F242-173-333
Declaration of Entitlement for Guardian Benefits under Industrial Insurance
Used by a guardian or other person having custody of the minor or disabled children or dependents of a deceased worker to declare their entitlement to receive the pension benefits for those children/dependents in their care and custody.
 Form
 F242-173-222
Declaration of Entitlement for Totally Disabled Worker Benefits Under Industrial Insurance
Used by a totally permanently disabled worker. This form must be completed, signed, notarized and returned to L&I within 30 days for non interruption of benefits.
 Form
 F242-173-444
Declaration of Entitlement for Widow or Widower Benefits Under Industrial Insurance
Used by the widow/widower whose spouse died of a work related injury or accident. This form must be completed, signed, notarized and returned to L&I within 30 days for non interruption of your benefits.
 Form
 F242-173-111
Doctor''s Worksheet for Rating Cervical and Cervico-Dorsal Impairment
Doctor''s Worksheet for Rating Cervical and Cervico-Dorsal Impairment
 Form
 F252-056-000
Doctor''s Worksheet for Rating Dorso-Lumbar & Lumbo-Sacral Impairment
This worksheet is to help the attending physician perform impairment rating on their patients with permanent partial disability of the Dorso-Lumbar or Lumbo-Sacral spine.
 Form
 F252-006-000
Doing Business with the State of Washington: A Guide to Washington State Bid Opportunities
Pamphlet/booklet: Provides an overview of bid opportunities and processes for Washington State government with specific contact information for the Department of Labor & Industries.
 Publication
 F101-087-000
Electrical Inspection Witness Statement
Used to gather information from a person who was a witness to electrical work that is being investigated by L&I.
 Form
 F500-087-000
Electrical Safety Tips for Your Home: Protect Your Family and Your Property
Pamphlet/Booklet: Provides information to help consumers properly handle electrical equipment and appliances, know the required permits and inspections for electrical work, and verify licenses and certifications before having electrical work performed.
 Publication
 F500-115-000
Electrical Work on Commercial Property: What You Should Know Before Work Begins
Fact Sheet: Explains to commercial property owners the importance of electrical permits, inspections and approvals. An electrical permit is required for most new, remodel and maintenance electrical work.
 Publication
 F500-109-000
Electrical Work on Residential Property: What You Should Know Before Work Begins
Fact Sheet: Explains to property owners the importance of electrical permits, inspections and approvals. An electrical permit is required for most new, remodel and maintenance electrical work.
 Publication
 F500-078-000
Employer''s Return-to-Work Guide

Pamphlet/booklet: Explains the benefits of ''return to work'' from the employer''s perspective, describes RTW options, and provides resource and contact information.

 Publication
 F200-003-000
Employers'' Guide to Self-Insurance in Washington State
Book: Explains the process for employers to provide their own industrial insurance (workers’ compensation) coverage in Washington State. Also reviews surety requirements for self-insurance, reporting and recordkeeping requirements, claims processing, and compliance and legal issues.
 Publication
 F207-079-000
Ergonomics Consultation: Free, Confidential, Powerful Impact on Your Bottom Line

Pamphlet: Provides information to employers interested in a free ergonomics consultation for their business. Explains the importance of workplace ergonomics and how L&I can help to assess injury-causing tasks, and help develop an ergonomics program.

 Publication
 F417-233-000
Excluded and Exempt Employments

Quick reference card: Provides a list of employments excluded from workers'' compensation coverage, including those eligible for optional coverage. This information is part of the publication, Workers’ Compensation Record Keeping and Report Guides.

 Publication
 F214-013-000
F245-392-000 Resource Utilization Group (RUG) Residential Care Services for L&I Injured Workers (In place of MDS 3.0 beginning October 1, 2010.)
Filled out by the provider when they treat an injured worker. See web links below for: Latest payment amounts, Updates and corrections, and Review payment policy. For use in place of Minimum Data Set (MDS) 3.0 beginning October 1, 2010.
 Form
 F245-392-000
Facts About Construction Liens
Fact sheet: Explains the basics of the construction lien law to help consumers protect themselves.
 Publication
 F625-017-000
Facts about Medical Gas Piping Installer Endorsement
Fact sheet: Explains training requirements and the endorsement process for medical gas piping installers.
 Publication
 F627-026-000
Facts about State Certification for Plumbers
Fact sheet: Explains plumber classifications, certification requirements, including required exams, and the application and renewal processes, including continuing education requirements.
 Publication
 F627-022-000
Fall Protection Basics for Construction Activities

Booklet: Provides an overview of revised fall protection rules and requirements for construction activities effective April 1, 2013.

 Publication
 F414-154-000
Fall Protection: Responding to Emergencies
Book: This guide is for employers and for employees who work from exposed, elevated surfaces. It covers the following: what to do to prevent fall-related emergencies and how to respond promptly if a fall-related emergency occurs. Includes illustrations of aided-rescue equipment systems.
 Publication
 F417-208-000
Farm Labor Contractor Certified Payroll
Farm Labor Contractor Certified Payroll
 Form
 F700-147-000
Faulty Water Heaters and Kids Don''t Mix
Fact sheet: Designed for operators of childcare facilities, this fact sheet explains the importance of keeping boilers and pressure vessels operating safety. Provides an overview of inspection requirements, frequency, and fees.
 Publication
 F620-059-000
FileFast postcard handout for workers
Handout (4.25 x 6): Explains to workers why and how to file an accident report online or by phone following an injury; also reminds them to stay in contact with employer and L&I.
 Publication
 F242-398-000
FileFast poster for workers
Poster (8.5 x 11): Explains to workers why and how to file an accident report online or by phone following an injury and reminds them to stay in contact with employer and L&I.
 Poster
 F242-399-000
FileFast wallet card for workers
Wallet card (3.5 x 2): Reminds workers of FileFast web address and number for call center.
 Publication
 F242-400-000
Five Steps to File
Flyer: Reviews the steps for filing workers'' compensation quarterly reports online and lists the filing due dates.
 Publication
 F212-243-000
Forklift Safety Guide
Book: Provides general information on kinds of forklifts, principles of physics that apply to forklifts, training requirements for forklift operators, basic operator safety rules, dangers of carbon monoxide, and safety while servicing a forklift.
 Publication
 F417-031-000
Four Steps to Proper Lifting
Pictures of a person lifting a large box correctly along with tips on how to correctly lift a large item safely. Get poster printing tips.
 Poster
 FSP0-918-000
Frequently Asked Questions about Job Modifications
Fact sheet: Answers questions employers, workers and doctors may have about job modifications, including when to request a job-modification consultant and who pays for the costs involved.
 Publication
 F245-057-000
Fryer Safety
Tips on deep frying safety. Get poster printing tips.
 Poster
 FSP0-905-000
Getting Back to Work: It''s Your Job and Your Future
Pamphlet/booklet: Briefly explains steps to return to work quickly and minimize the economic impact of time-loss. Also provides helpful resources. Intended for injured workers.
 Publication
 F200-001-000
Green Power Generation System Installation: What You Should Know Before Doing Any Electrical Work
Fact sheet: Explains that an electrical permit and inspection are required for most new, remodel, and maintenance electrical work. Provides information specific to the installation of green power generation systems.
 Publication
 F500-116-000
Group vs. Individual Retrospective Rating Participation
Fact sheet: Provides information to employers interested in the Retrospective Rating Program who want to compare group vs. individual participation. Explains the differences in minimum premium amount, fees, services, refund potential, choice, and risk. Also includes contact information for enrolling.
 Publication
 F225-016-000
Guide to Crew Safety Meetings
Pamphlet/booklet: Provides a succinct guide to conducting crew safety meetings for general industry and the construction industry. Includes a format for recording meeting minutes.
 Publication
 F417-043-000
Guidelines for Selecting Reserve Trees
Book: Provides technical guidance on retaining reserve trees in concert with safe work practices and forest and wildlife management goals. Produced cooperatively by state and federal agencies and industry groups.
 Publication
 F417-092-000
Hazard Documentation Worksheet
Hazard Documentation Worksheet for use by L&I compliance staff to describe, measure and comment on workplace hazards.
 Form
 F418-031-000
HCFA Proprietary Format Companion Guide
This guide details the HCFA proprietary format structure and provides information regarding electronic billing to the department via Provider Express Billing (PEB).
 Form
 F245-394-000
Hearing Impairment Calculation Worksheet
Used by the attending doctor to determine hearing loss.
 Form
 F252-007-000
Help for Injured Workers of Self-Insured Businesses
Information card: Introduces the Office of the Ombudsman for Self-Insured Injured Workers. The ombudsman is appointed by the Governor to serve as an independent advocate for the rights of injured workers of self-insured employers.
 Publication
 F207-201-000
Helping Providers Understand the Crime Victims Compensation Program
Fact sheet: Answers questions doctors and mental health counselors may have about the Crime Victims Compensation Program and billing for services. Also suggests steps these providers can take to speed up reimbursement.
 Publication
 F800-102-000
High Noise Area, Wear Hearing Protection
Cartoon of a guy plugging his ears with his fingers while his hearing protection is wrapped around his neck with the words ''High Noise Area'' above his head. Get poster printing tips.
 Poster
 FSP1-065-000
Historical Boilers Inspection Guideline
Inspection sheet for boiler inspectors. 4 pages.
 Form
 F620-043-000
Home Modification for Workers with Catastrophic Injuries

Fact sheet: Answers questions about the home modification benefit in Washington State''s workers'' compensation program, who qualifies, what L&I can pay, and where to get more information.

 Publication
 F252-060-000
Hotline Tips for Medical Services Providers
Fact sheet: Provides tips to help medical service providers quickly obtain answers to claims and billing questions. Introduces L&I''s Provider Hotline, Interactive Voice Response Message System and online Claim & Account Center.
 Publication
 F248-040-000
Housing and Board Cost Encumbrance
To record the costs for housing and board. For use only with plans approved after 1/1/2008.
 Form
 F245-372-000
How to Become a Certified Electrician: What You Need to Know about Certification in Washington State
Fact sheet: Provides information about getting a trainee card and outlines the electrical training and experience required to be certified as an electrician in Washington State.
 Publication
 F500-117-000
How to Ride Safely on Elevators, Escalators and Moving Walks
Pamphlet/booklet: Provides safety tips and interesting facts to promote safe use of elevators, escalators and moving walks.
 Publication
 F621-084-000
If Family Members Work for You, Know Your Obligations (English/Chinese)
Fact sheet: Provides an overview and resources to know your obligations when you have family members working for you. Relatives, including children, must be treated as employees with the same rights as any other paid worker in the state of Washington
 Publication
 F101-077-808
If Family Members Work for You, Know Your Obligations (English/Korean)
Fact sheet: Provides an overview and resources to know your obligations when you have family members working for you. Relatives, including children, must be treated as employees with the same rights as any other paid worker in the state of Washington.
 Publication
 F101-077-707
If Family Members Work for You, Know Your Obligations (English/Russian)
Fact sheet: Provides an overview and resources to know your obligations when you have family members working for you. Relatives, including children, must be treated as employees with the same rights as any other paid worker in the state of Washington.
 Publication
 F101-077-404
If Family Members Work for You, Know Your Obligations (English/Vietnamese)
Fact sheet: Provides an overview and resources to know your obligations when you have family members working for you. Relatives, including children, must be treated as employees with the same rights as any other paid worker in the state of Washington.
 Publication
 F101-077-505
Incident Report Boiler or Pressure Vessel
Used for the reporting of incident with boilers or a pressure vessels.
 Form
 F620-044-000
Independent Contractors

Quick reference card: Provides information to help determine whether a "subcontractor" working for you meets the legal requirements to be an independent contractor, or whether he/she is actually a covered worker for workers'' compensation (industrial insurance) purposes. This information is part of the publication, Workers’ Compensation Record Keeping and Report Guides.

 Publication
 F214-012-000
Independent Medical Exam Comments
Used by the injured worker to provide comments to L&I about their recent medical exam by an IME.
 Form
 F245-053-000
Independent Medical Exam Template
Template used by a doctor during an independent medical exam.
 Form
 F245-058-000
Independent Medical Examination Fax Cover Sheet
Independent Medical Examination Fax Cover Sheet
 Form
 F245-383-000
Individual Retrospective Rating Plan Agreement
Used by employers to set up an agreement between them and L&I authorizing their participation in retrospective rating.
 Form
 F250-003-000
Intent to Hire Preferred Worker
Used by employers when hiring a preferred worker. This form must be received within 60 days of the hiring and the Preferred Worker Employer''s Job Description (F280-022-000) form must be attached.
 Form
 F280-010-000
Intent to Hire Preferred Worker with Developmental Disabilities
Used by employers rehiring developmentally disabled workers after an industrial injury. This form requests preferred worker status and shows the physical demands of the work to be performed by the worker. The Preferred Worker Employer''s Job Description (F280-022-000) should be attached.
 Form
 F280-011-000
Interpreter Services for Injured Workers and Crime

Flier: Describes interpreter services available to injured workers and crime victims. Covers how to get an interpreter; who can interpret and get paid for it; and basics of interpreter''s professional conduct.

 Publication
 F245-412-000
Investigation Report
To notify L&I on any electrical work that you think is illegal.
 Form
 F500-076-000
Is Retrospective Rating Right for You?
Pamphlet: Provides information about L&I''s Retrospective Rating Program. In Retro, employers can earn a partial refund of workers'' compensation premiums if they reduce workplace injuries and lower associated claim costs.
 Publication
 F250-006-000
Job Site Safety: Wear Your Hard Hat
Poster: Visual reminder you can print for posting at appropriate job sites and use in safety training, crew or safety committee meetings.
 Poster
 FSP0-907-000
Keep Your Employees Safe and Working

Pamphlet/booklet: Describes the benefits of free employer consultations offered by L&I''s Division of Occupational Safety and Health (DOSH). These services include on-site safety and/or industrial hygiene consultations, ergonomics assistance and risk management advice.

 Publication
 F417-209-000
Keep Your Water Heater Safe
Pamphlet/booklet: Describes the process for conducting an annual safety test of a residential water heater. Includes illustrations.
 Publication
 F620-048-000
Keys to Retro Success

Fact sheet: Provides information to employers who are considering joining a Retrospective Rating (Retro) group.Contains questions and suggestions to help determine if Retro is right for a business and information regarding annual participation.

 Publication
 F225-018-000
Keys to Safety
Picture of two keys with the words ''Skills'' and Knowledge'' on them. Get poster printing tips.
 Poster
 FSP0-954-000
Know Your Lockout Tagout Safety Procedures
Poster: Visual reminder you can print for posting in appropriate workplaces. Two options available for download and/or printing.
 Poster
 FSP1-063-000
L&I Chiropractic Consultant Application
This application is for doctors applying for second opinion examiner (consultant) status. Current consultants do not need to reapply.
 Form
 F245-393-000
L&I Facility Use Application and Agreement for Government Agencies
Use this form if you are a government agency wanting to use the L&I facility located at 7273 Linderson Way SW; Tumwater, WA. (4 pages)
 Form
 F120-097-000
Ladder Safety
Picture of a ladder with safety tips on the rungs. Get poster printing tips.
 Poster
 FSP0-951-000
Lessons for Lifting & Moving Materials
Book: Identifies work areas, tasks and procedures that place employees at risk of injury. Describes and illustrates methods that help reduce the risk of injury.
 Publication
 F417-129-000
Letter of Intent for School Enrollment
Use by a full-time student who is entitled to receive pension benefits. The student must be at least 18 years old and no older than 23 years old. This form is to prove the students intention to register in an accredited school during the next quarter/semester.
 Form
 F242-382-000
License Requirements for Elevator Mechanics and Contractors
Fact sheet: Explains licensing and testing requirements for mechanics who work on elevators and for contractors who install, repair or maintain elevators.
 Publication
 F621-070-000
Limited Liability Companies (LLC)

Quick reference card: Reviews the requirements for members or managers of limited liability companies to be exempt from workers'' compensation (industrial insurance) coverage. This information is part of the publication, Workers’ Compensation Record Keeping and Report Guides.

 Publication
 F214-021-000
Making the Best Treatment Choice for Your Chronic Low-back Pain
Fact sheet: Reviews the options that an injured worker with low-back pain should consider in determining the best treatment choice.
 Publication
 F252-081-000
Master Level Counselor Provider Account Application for Crime Victims

Master Level Counselor Provider Account Application for Crime Victims

 Form
 F800-053-000
Medical Payment Guidance

Flyer: Describes how a payment for health-care services is mailed separately from the explanation for the payment (the remittance advice). An illustration explains how to link a payment with its explanation. Also includes information about how providers can always find their remittance advices online through L&I''s Provider Express Billing.

 Publication
 F248-366-000
Non-Compliance Report - Boiler & Pressure Vessel Inspection
Used by L&I inspectors when a boiler or pressure vessel does not pass inspection. You can only mail or fax this form to L&I. E-mailed forms are NOT accepted.
 Form
 F620-012-000
Notice of Deficiencies (Crane/Derrick Certification Examination)
Use this form for noting any deficiencies of cranes, derricks, material handling devices, spouts, suckers and similar equipment.
 Form
 F416-054-000
Notice of Independent Medical Exam No-Show or Late Cancellation
Notice of Independent Medical Exam No-Show or Late Cancellation
 Form
 F245-382-000
Occupational Disease Employment History Hearing Loss
Used by injured worker who has filed an occupational hearing loss claim to report their employment history and the nature of the noise exposure at each job. F262-013-111 is the continuation sheet.
 Form
 F262-013-000
Occupational Disease Employment History Hearing Loss (Continuation)
Used by injured worker who has filed an occupational hearing loss claim to report their employment history and the nature of the noise exposure at each job. This form is a continuation of form F262-013-000.
 Form
 F262-013-111
Occupational Hearing Loss Questionnaire
Used by injured worker who has filed an occupational hearing loss claim to provide more specific information regarding how the hearing loss occurred. This is requested by the Claim Manager and sent to the Injured Worker.
 Form
 F262-016-000
Office Ergonomics: Practical solutions for a safer workplace
Book: Provides information and tools to analyze office jobs, find problems and develop ergonomic solutions.
 Publication
 F417-133-000
On-the-Job Training
Postcard: For employers; summarizes the benefits of providing on-the-job training to an injured worker. The other side is for injured workers who want to return to work; explains how on-the-job training can help them. Includes website address and contact information.
 Publication
 F200-021-000
Online Electrical Services: Tools for Property Owners, Contractors and Electricians
Fact Sheet: Describes the online services available from L&I''s Electrical Program, including URLs for different topics covered on the Web, how to sign up for the Electrical listserv (to receive updates by e-mail), and how to sign up for the monthly e-newsletter, also provided by e-mail.
 Publication
 F500-113-000
Operating Boilers Safely
Fact sheet: Explains what you need to know to keep your boilers and pressure vessels operating safety. Provides an overview of inspection requirements, frequency and fees.
 Publication
 F620-025-000
Operating Power Lawn and Yard-care Equipment: Safety for Teen Workers
Fact sheet: Overview of safety practices, plus information on what equipment employees under 18 can and cannot operate. Provides resources on requirements for hearing protection and PPE (personal protective equipment).
 Publication
 F700-010-000
Option 2: What You Need to Know, Vocational Rehabilitation Services
Booklet: Explains what happens when an individual selects "Option 2" and choose not to participate in the approved training plan.
 Publication
 F280-036-000
Overhead Crane Bridge, Monorail, Gantry Worksheet for Construction
Overhead Crane Bridge, Monorail, Gantry Worksheet for Construction.
 Form
 F416-141-000
Pension Bond Rider
Used by a self-insured employer to change items on the surety document such as amount of pension bond issued to secure a total permanent disability claim.
 Form
 F207-120-000
Personal Protective Equipment (PPE) Guide
Book: This guide helps employers comply with the WISHA Personal Protective Equipment rules. It covers general personal protective equipment and PPE requirements used to protect the head, eyes and face, hand and arm, foot and leg, and body (torso) in most work environments.
 Publication
 F417-207-000
Pharmacy Companion Guide
This guide details the HIPAA ASC X12N 004010 format structure for 835 Pharmacy Remittance Advice and provides information regarding electronic billing to the department via Provider Express billing (PEB)
 Manual
 F245-400-000
Plan Development Recommending Plan Approval Routing Sheet
Routing slip that accompanies the Vocational Services Closing Cover Sheet (F252-028-000) which is used to close vocational services to an injured worker only if you are recommending Plan Approval. For all other closing reports, use Vocational Closing Report Routing Sheet (F252-027-000).
 Form
 F280-013-000
Plan Development: What Are My Rights & Responsibilities?
Booklet: Explains the basics of the plan development phase of vocational services to injured workers. L&I send this booklet to injured workers when they are referred for plan development services. The assigned vocational rehabilitation counselor is required to review this booklet with the worker at their initial face-to-face meeting.
 Publication
 F280-018-000
Plan for and Pay Your Taxes
Information card: Introduces Washington State''s 28-minute DVD that covers state business taxes and workers'' compensation premiums and provides information on how to file.
 Publication
 F101-091-000
Plan Time Encumbrance
To record the work plan time. For use only with plans approved after 1/1/2008.
 Form
 F245-376-000
Plumber Request for Change of Address
Plumber Request for Change of Address
 Form
 F627-039-000
Pocket Guide to Worker Rights

Brochure: This guide is to help workers understand their rights in Washington State. It includes information about safety and health protection, minimum wage and overtime pay, prevailing wage, rest and meal breaks, sick leave, family leave, workers'' compensation benefits and retaliation.

 Publication
 F101-165-000
Power of Attorney for Electronic Remittance Advice
Providers complete this form to authorize a clearinghouse or third party to receive the EDI 835 Electronic Remittance Advice file from L&I''s Provider Express Billing (PEB).
 Form
 F248-355-000
Pre-Inspection Checklist for Hot Water Heating or Hot Water Supply Boilers
Checklist which reflects the most common violations encountered by Field Inspectors. This checklist should be gone through prior to requesting inspection of Hot Water Heating or Hot Water Supply Boilers
 Form
 F620-050-000
Pre-Inspection Checklist for Potable Water Heaters - ASME "HLW" Stamped Water Heaters
Checklist which reflects the most common violations found by Field Inspectors. This checklist should be gone through prior to calling for an inspection of Potable Water Heaters-HLW
 Form
 F620-051-000
Preferred Worker Employers Job Decsription
Used by the employer to describe the job for the preferred worker. This form is reviewed by a vocational services consultant to ensure that the offered job is consistent with the worker''s medical restrictions.
 Form
 F280-022-000
Preferred Worker Program

Pamphlet/booklet: Describes the Preferred Worker Program and the benefits employers receive when hiring a preferred workers. Iin general, these are workers whose work-related injury or occupational disease prevents them from returning to their old job.

 Publication
 F280-021-000
Preventing Slips and Falls
Information on how to prevent slips and falls with your footwear, housekeeping and also some general awareness tips. Get poster printing tips.
 Poster
 FSP0-904-000
Protect Yourself and Your Family from Lead Poisoning
Pamphlet/booklet: Explains the risks of lead exposure for workers who work on outdoor steel structures, and harmful effects on workers and their families. It includes a poster about the importance of safe work practices and procedures.
 Publication
 F417-214-000
Protecting Yourself and Your Workers from Poison Oak and Ivy (English/Spanish)
Pamphlet/booklet: Discusses the effects of poison oak and ivy, where it is found in Washington State, how to control growth and protect workers from exposure.
 Publication
 F413-047-000
Protegiendo a los trabajadores de Washington (Protecting Washington Workers)
DVD: An innovative tool to teach Spanish-speaking workers about workplace rights while introducing English terminology.
 DVD
 F130-004-909
Provider Network Agreement
The provider network agreement for participation in the health care provider network for injured workers covered by Washington State Fund and self-insured employers.
 Form
 F245-397-000
Questions and Answers about Electrical Safety
Fact Sheet: Answers questions about training and certification/licensing requirements for those who perform electrical installations, and electrical work that requires a permit and inspection.
 Publication
 F500-110-000
RCW 43.22.380 Exemptions Fire and Safety Checklist for Vendor/Medical Conversion Units
Generic Checklist to determine if the particular installation includes all requirements prior to calling for an inspection. Must be able to answer YES to all questions prior to calling.
 Form
 F622-073-000
Record Keeping

Quick reference card: Identifies the type of records employers, including construction contractors, need to keep to allow L&I to compute premiums. This information is part of the publication, Workers’ Compensation Record Keeping and Report Guides.

 Publication
 F214-011-000
Report All Injuries Promptly
Large words: Report All Injuries Promptly. Get poster printing tips.
 Poster
 FSP1-004-000
Request for Approval of Proposed Standards
Request for new apprenticeship standards.
 Form
 F100-049-000
Request for Cancellation of New Apprenticeship Committee
To request a cancellation of a new apprenticeship committee which never has a "Request for New Standards" approved by the WSATC
 Form
 F100-510-000
Request for Cancellation of Program
Used for cancelling an apprenticeship program.
 Form
 F100-303-000
Request for Revision of Standards
Used to request a revision of standards except for committee members.
 Form
 F100-030-000
Restaurant Employee Safety Orientation Checklist
Fact Sheet: Download this checklist to help with the safety orientation of new restaurant employees.
 Publication
 F700-140-000
Retrospective Rating Enrollment Decisions
Fact sheet: Information for employers regarding choices they should make when enrolling in the Retrospective Rating (Retro) program including plan type, single-loss limit and upper and lower loss-ratio limits.
 Publication
 F225-017-000
Robberies and Abusive Customers: Tips for Preventing Injuries
Tips on handling cash and how to have a safer restaurant or retail environment. Get poster printing tips.
 Poster
 FSP0-919-000
Robberies and Abusive Customers: Tips for Preventing Injuries
Tips on handling cash and how to have a safer restaurant or retail environment. Get poster printing tips.
 Publication
 FSP0-919-000
Safe Ways - Fork Lift Safety
Safety tips on using a fork lift. Get poster printing tips.
 Poster
 FSP0-978-000
Safety & Health Video Library & Resource Center
Pamphlet: Introduces the center and available services. You can borrow safety training videos and DVDs and order workplace posters. Also contains contact information.
 Publication
 F417-222-000
Safety Comes Thru Job Training
A supervisor having a discussion with his crew. Get poster printing tips.
 Poster
 FSP0-901-000
Safety for Commercial Dive Teams
Fact sheet: Provides an overview of safety for commercial dive teams, summarizes the key requirements of commercial diving regulations (WAC 296-37), and includes contact information.
 Publication
 F417-226-000
Safety Steps for Supervisors and Employees in Restaurants
Fact Sheet: A useful summary of the responsibilities both employers and employees share for a safe workplace. This can be shared with new employees during their initial orientation.
 Publication
 F700-139-000
Self-Insurance Electronic Data Reporting System (SIEDRS) Enrollment Form
Used by self-insured employers and third party administrators to enroll for participation in the Self Insurance Electronic Data Reporting System (SIEDRS). F207-197-000 is SIEDRS (Self-Insurance Electronic Data Reporting System) Data Change Request.
 Form
 F207-193-000
Self-Insurance Vocational Services Closing Cover Sheet
Used by self-insured employers, their representatives, and vocational counselors to summarize the outcome of a vocational rehabilitation plan when submitting the closing report.
 Form
 F207-171-000
Self-Insurer''s Bond - Existing Liabilities
Used to provide collateral for a self-insured program.
 Form
 F207-068-000
Shop and Field Inspection Report
Used by L&I inspectors when they inspect boilers.
 Form
 F620-027-000
SIF-4 Self Insured Employer''s Request for Denial of Claim
Used by self-insured employers or their representatives to notify an injured worker that the employer or representative is requesting that L&I deny their claim.
 Form
 F207-163-000
Small Business Liaison Info Card
Introduces L&I''s Small Business Liaison and the services provided, along with information on subscribing to the e-newsletter, L&I News for Small Business.
 Publication
 F101-088-000
Special Escrow Account - Amendment Agreement
Used by a self-insured employer to amend or change items on the surety document such as the amount of the escrow agreement used as collateral.
 Form
 F207-137-000
Special Escrow Agreement
Used by self-insured employer as a means to provide surety. This is an agreement between the self-insurer and the bank to hold these securities in trust as collateral for its self-insured program.
 Form
 F207-039-000
Standard Exception Classification

Quick reference card: Provides basic information about standard exception classifications, which can be separately rated from the basic business classification for determining industrial insurance (workers'' compensation) premiums. This information is part of the publication, Workers’ Compensation Record Keeping and Report Guides.

 Publication
 F214-016-000
START Program (Safety through Achieving Recognition Together)
Fact sheet: Provides an overview of START, a program that recognizes occupational safety and health excellence in small businesses. Includes program requirements and benefits.
 Publication
 F417-229-000
Stay Clear of Suspended Loads
Pictures a guy under a suspended wooden carton. Get poster printing tips.
 Poster
 FSP0-908-000
Sticker - Emergency Information
 CD
 FSP0-900-001
Stop Work Payroll Report
Stop Work Payroll Report
 Form
 F262-043-000
Strategic Plan
Booklet: Explains the strategic direction of the Department of Labor & Industries. Includes a message from the director, goals, objectives and strategies.
 Publication
 F101-099-000
Supplemental Agreement Third Party Pharmacy Provider
This agreement is to define access, performance and legal requirements for third party pharmacy billers who submit bills to and receive payment from L&I on behalf of pharmacy providers. This agreement authorizes L&I to accept and remit monies due the Pharmacy using a third party pharmacy biller.
 Form
 F249-021-000
Surety Rider
Used by a self-insured employer to amend or change items on the surety document such as the amount of a surety bond used as collateral.
 Form
 F207-134-000
Targeting Fraud and Abuse in Washington State''s Worker''s Compensation Program: 2005 Report to the Legislature
Booklet/pamphlet: Provides an overview of L&I''s activities to deter and detect workers'' compensation fraud and abuse by workers, employers and medical providers. Includes statistics on dollars collected and costs avoided.
 Publication
 F262-251-000
Targeting Fraud and Abuse in Washington State''s Workers Compensation Program: 2006 Report to the Legislature
Booklet/pamphlet: Provides an overview of L&I''s activities to deter and detect workers'' compensation fraud and abuse by workers, employers and medical providers. Includes statistics on dollars collected and costs avoided.
 Publication
 F262-276-000
Targeting Fraud and Abuse in Washington State''s Workers'' Compensation Program: 2007 Report to the Legislature
Booklet/Pamphlet: Provides an overview of L&I''s activities to deter and detect workers'' compensation fraud and abuse by workers, employers and medical providers. Includes statistics on dollars collected and costs avoided.
 Publication
 F262-280-000
Targeting Fraud and Abuse in Washington State''s Workers'' Compensation Program: 2008 Report to the Legislature
Booklet/Pamphlet: Provides an overview of L&I''s activities to deter and detect workers'' compensation fraud and abuse by workers, employers and medical providers. Includes statistics on dollars collected and costs avoided.
 Publication
 F262-032-000
Targeting Fraud and Abuse in Washington State''s Workers'' Compensation Program: 2009 Report to the Legislature
Booklet/Pamphlet: Provides an overview of L&I''s activities to deter and detect workers'' compensation fraud and abuse by workers, employers and medical providers. Includes statistics on dollars collected and costs avoided for fiscal year 2009.
 Publication
 F262-034-000
Targeting Fraud and Abuse in Washington State''s Workers'' Compensation Program: 2010 Report to the Legislature
Booklet/Pamphlet: Provides an overview of L&I''s activities to deter and detect workers'' compensation fraud and abuse by workers, employers and medical providers. Includes statistics on dollars collected and costs avoided for fiscal year 2010.
 Publication
 F262-044-000
Taxi-for-hire Vehicle Reporting Requirements
Fact sheet: Provides information for the for-hire industry about mandatory coverage for all for-hire drivers. Includes the different reporting methods and due dates of quarterly reports.
 Publication
 F212-245-000
Ten Safe Handling Hints for Knives
Shows ten tips on handling a knife safely. Get poster printing tips.
 Poster
 FSP0-903-000
Ten Steps for Avoiding Burns
Tips on how to avoid burns while cooking. Get poster printing tips.
 Poster
 FSP0-906-000
Termination of Agreement (Rescission)
To be filled out by the injured worker who wants to return hearing aids.
 Form
 F245-050-000
The ABCs of Classifications in Washington
Book: Aids in understanding Washington State''s workers'' compensation classification system and how classifications are applied to different types of businesses.
 Publication
 F213-022-000
The Apprenticeship Advantage: Earn While You Learn!
Fact sheet: Introduces apprenticeship to younger people. Explains the benefits of apprenticeship, a program of study where apprentices earn wages while learning a skilled profession. Includes contact information for L&I''s apprenticeship coordinators around the state.
 Publication
 F100-022-000
The Best Accident Insurance - To observe all safety regulations
Picture of a guy with Saftey Policy and Rules in his hand. Get poster printing tips.
 Poster
 FSP0-915-000
Tower Crane Worksheet for Construction Industry
 Form
 F416-044-000
Using Apprentices on Public Works and Other Projects
Pamphlet: Provides a quick overview of the rules for using apprentices on public works projects, including apprentice utilization. Also describes the benefits of apprenticeship and where to get more information.
 Publication
 F100-529-000
Verification of School Enrollment

Used by the student and a school official each quarter to verify school enrollment.

 Form
 F242-055-000
Vocational Technical Stakeholder Group (VTSG) Application
This form is for recruiting private sector vocational counselors to be on the Vocational Technical Stakeholder Group (VTSG). The form is made available on the department’s vocational website when recruiting for new members to assist the department in addressing vocational issues and formulating policy. Prospective applicants are expected to download, sign, and return the form to PSRS for consideration.
 Form
 F280-049-000
Voluntary Protection Program (VPP)
Fact sheet: Provides an overview of the VPP, a program that recognizes occupational safety and health excellence. Identifies benefits and includes testimonials from companies awarded VPP status.
 Publication
 F417-221-000
Walk, Don''t Run
Timeless reminder to walk, don''t run, showing a banana peel. Get poster printing tips.
 Poster
 FSP1-051-000
Washington State Apprenticeship Programs Catalog
Book: Provides an overview of apprenticeship, explains general requirements, lists the apprenticeship programs in Washington State and, and provides contact information. The version available online may contain more up-to-date information than the June 2012 printed edition.
 Publication
 F100-041-000
Washington Workers Insured Out-of-State: Employer’s Supplemental Quarterly Report for Workers’ Compensation
The purpose of 212-233-000 Supplemental reporting form is to allow employers to report out-of-state wages and hours as per the requirement in WAC 296-17-25203(8).
 Form
 F212-233-000
Watch Where You Step
Large lettering: Watch Where You Step. Get poster printing tips.
 Poster
 FSP1-055-000
Well...My Daddy Wears ''Em
Little boy wearing his daddy''s hard hat, eye protection, gloves and boots. Get poster printing tips.
 Poster
 FSP1-010-000
What Are Your Rights as a Worker? (English/Cambodian)
Fact sheet: Provides a brief overview of the worker rights administered by the Department of Labor and Industries. These include certain employment-related rights and rights pertaining to workplace safety and workers'' compensation benefits.
 Publication
 F101-061-606
What Are Your Rights as a Worker? (English/Korean)
Fact sheet: Provides a brief overview of the worker rights administered by the Department of Labor and Industries. These include certain employment-related rights and rights pertaining to workplace safety and workers'' compensation benefits.
 Publication
 F101-061-707
What Are Your Rights as a Worker? (English/Russian)
Fact sheet: Provides a brief overview of the worker rights administered by the Department of Labor and Industries. These include certain employment-related rights and rights pertaining to workplace safety and workers'' compensation benefits.
 Publication
 F101-061-404
What Are Your Rights as a Worker? (English/Vietnamese)
Fact sheet: Provides a brief overview of the worker rights administered by the Department of Labor and Industries. These include certain employment-related rights and rights pertaining to workplace safety and workers'' compensation benefits.
 Publication
 F101-061-505
What Are Your Rights When You Work for a Farm Labor Contractor? (English/Spanish) / ¿Cúales son sus derechos cuando trabaja para un contratista de trabajadores agrícolas?
Fact sheet: Explains workers'' rights when they are employed by a farm labor contractor. Topics covered include workplace safety, rest and meal breaks, and help if injured on the job.
 Publication
 F700-067-909
What You Need to Know if You Don''t Get Paid: A Worker''s Guide to the Washington State Wage Payment Act-English/Spanish (Lo que necesita saber si no recibe su pago: Una guía para el trabajador de la ley del pago de salario del) estado de Washington
Fact sheet: Summarizes workers'' rights and responsibilities regarding minimum wage, pay, work hours and overtime and explains how to file a wage complaint. Includes answers to several commonly asked questions.
 Publication
 F700-153-909
When a Loved One Dies at Work

Brochure: Provides information to loved ones of workers who died from a job-related injury or illness, including how to apply for survivor benefits. Explains the L&I fatality investigation and how family members can stay informed of the investigation''s status.

 Publication
 F417-240-000
Worker and Community Right-to-Know Program
Fact sheet: Provides an overview of the Worker and Community Right-to-Know (RTK) Program authorized by legislation in 1986. Explains the RTK fees, education on hazardous substances that the fees support, who pays the fees and how they are calculated.
 Publication
 F413-075-000
Workers'' Comp Fraud Hurts YOU
Pamphlet: Explains the impacts of workers'' comp fraud and L&I''s efforts to prevent and find fraud by workers, employers, contractors, and medical providers.
 Publication
 F262-279-000
Workers'' Compensation Discrimination-English/Spanish (Discriminación porque se lesionó en su trabajo)
Fact sheet: Explains workers'' legal right to file a workplace injury claim and how to file a complaint if discrimination has occurred.
 Publication
 F262-249-909
Working Safely with Asbestos in Brake and Clutch Linings
Pamphlet/booklet: Reviews the health hazards of asbestos exposure, use of asbestos in brake and clutch linings, employer''s responsibilities, how employees can protect themselves, employee rights, and where to get help with waste management.
 Poster
 F413-049-000
Working Safely with Asbestos in Brake and Clutch Linings
Pamphlet/booklet: Reviews the health hazards of asbestos exposure, use of asbestos in brake and clutch linings, employer''s responsibilities, how employees can protect themselves, employee rights, and where to get help with waste management.
 Publication
 F413-049-000
Workplace Posters: Required and Recommended
Fact sheet: Lists posters that Washington State and federal agencies require or recommend employers post in their places of business. The URLs for posters available online and and telephone numbers to request printed posters are also provided. Also includes online resources and contact numbers for state agencies that issue posters.
 Poster
 F101-054-000
Workplace Posters: Required and Recommended
Fact sheet: Lists posters that Washington State and federal agencies require or recommend employers post in their places of business. The URLs for posters available online and and telephone numbers to request printed posters are also provided. Also includes online resources and contact numbers for state agencies that issue posters.
 Publication
 F101-054-000
Workplace Violence: Awareness and Prevention for Employers and Employees
Book: Describes four types of workplace violence, outlines steps to minimize and prevent violent acts, and discusses potential risk factors and prevention techniques.
 Publication
 F417-140-000
Young Workers in Agriculture/Trabajadores jóvenes en la agricultura (English/Spanish)

Pamphlet/booklet: Answers many questions employers and minor workers have about employing minors. Covers agriculture work rules, including the necessary permits, hours and work conditions for workers 12-17 years of age.

 Publication
 F700-096-909
Your Body, Your Job: Preventing Carpal Tunnel Syndrome and Other Upper Extremity Musculoskeletal Disorders
Pamphlet/booklet: Reviews the symptoms and risk factors for carpal tunnel syndrome and several other musculoskeletal disorders that affect the shoulder, arm and elbow. Discusses prevention approaches and where to get more information.
 Publication
 F413-024-000
Your Daily Record of Hours Worked (English/Spanish) / Su Registro de Horas Trabajadas
Pamphlet/booklet: A pocket-sized bilingual booklet to encourage agricultural workers to keep track of their daily work hours and earnings.
 Publication
 F700-105-909
Your Independent Medical Exam (IME): Crime Victims Compensation Program
Fact Sheet: Provides answers to commonly asked questions about independent medical exams (IMEs) and contact information. Includes a form for requesting travel-related reimbursement for attending an IME.
 Publication
 F800-115-000
Your Independent Medical Exam: For Employees of Self-Insured Businesses
Pamphlet: Answers the most common questions about when and why an injured worker may be required to attend an independent medical exam. Includes the "IME Travel & Wage Reimbursement Request" form. This publication is for use only by self-insured businesses and their workers.
 Publication
 F207-202-000
Your Lungs, Your Work, Your Life: What You Should Know about Work-related Asthma (Russian)
Pamphlet/booklet: Briefly reviews the symptoms and causes of work-related asthma and explains prevention and treatment approaches.
 Publication
 F413-060-444
Your Privacy Is Important to Us (English/Spanish)
Fact sheet: Serves as L&I''s official privacy notice. States how L&I may use and share the pesonal information it collects. It also informs the public how they can file a complaint if they believe L&I has misused or inappropriately disclosed their personal information.
 Publication
 F101-055-909
Youth in Construction - English/Spanish (Adolescentes en construcción)
Booklet/pamphlet: Explains the limits on work teens under age 18 can perform in the construction industry, discusses the importance of training and emphasizes safety. Includes a checklist of "do''s" and "don''ts" for employers, plus other resources.
 Publication
 F700-145-909





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