Forms
Please see the following required forms for claim processing:  


Activity Prescription Form (APF)

Puget Sound Workers' Compensation Trust considers the effective use of the Activity Prescription Form (APF) as a best practice in occupational medicine. The form communicates an injured worker's physical restrictions and ability to work as well as the provider's treatment plans. In addition, workers' time-loss benefits depend on the APF and your chart notes.

Provider's Initial Report (PIR)

A Provider’s Initial Report (PIR) is completed by the Provider and the Employee and establishes a claim. When the completed PIR is received by the HR/Return to Work Coordinator or Puget Sound Workers' Trust the PIR will be matched with your claim number. If you have not yet filed the online claim you will be directed to our Employee Accidents and Injuries - File a claim page, to complete the online claim process.  

Time Loss Election Form

Employees who are injured on the job and will be off work for more than three days following the date of injury, may be eligible to supplement their time-loss benefits with sick, personal, vacation, comp or an other similar leave accrual benefit. If an employee is found eligible for time loss payments, the employee has a choice on how they wish to supplement the time loss payments. The required Time Loss Election Forms should be completed at the time of filing a  claim. Please print this form and visit our Employee - Work Injury and Compensation FAQ page for a further definition of supplemental options. 

Please see the following form to be completed by an employee returning from an extended medical-related leave:

Return to Work Review Form

To enable the District to adequately support an employee’s safe return to work after a medical-related leave, the returning employee will be required to complete a Return to Work Review form.  The form is to be submitted to either the HR Leave and Accommodations Coordinator or HR Return to Work Coordinator prior to return work in order to allow review, any needed approvals and communication of necessary information to the employee’s supervisor.  

 
If you have questions regarding forms, please contact your
HR/Return to Work Coordinator for further assistance.