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ELECTRONIC DISPOSITION CHECKLIST
HUMAN RESOURCES DEPARTMENT LIASON OR SUPERVISOR
PHONE
EMAIL ADDRESS
DISPOSITION REPORT DATE
EMPLOYEE NAME
CLAIM NUMBER
DATE OF INJURY
ADJUSTER
Select an adjuster from the list
Georgette Cumley (GCY)
Wally Johnson (WJ)
Unknown
Please check below which situation best describes the on-job-injury and work restrictions as indicated on the latest Designated Medical Provider’s (DMP) disposition form.
The above employee is being temporarily accommodated and is not missing any time from work.
The above employee is being temporarily accommodated and is missing time from work for medical appointments. (Note to Claimaint’s department:
Please Include a
Lost Time Report
)
The above employee is not being temporarily accommodated by the department and has been sent home pending the next medical appointment.
The above employee has no further work restrictions, and is released to perform regular duty.
The above employee has reached Maximum Medical Improvement (MMI).
DATE & TIME SUBMITTED
11/20/2008 5:43:37 PM
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