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Division of Federal Employees' Compensation (DFEC)

Field Nurse Handbook

Part 6


Part 6 - Communications and Documentation

Paragraph and Subject

Date

FNHB Trans. No.

Table of Contents

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1. Overview

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2. Communicating with the CE

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3. Communicating with the SN

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4. Documenting FN Communications and Nurse Interventions

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5. Initial Communications – Early DM Assignments

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6. Interim Communications – Early DM Assignments

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7. Formal Reports – Early DM Assignments

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8. The Initial Evaluation – Early DM Assignments

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9. The Progress Report – Early DM Assignments

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10. The Closure Report – Early DM Assignments

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11. Documenting Extension Requests – Early DM Assignments

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12. Formal Reports – Task-Based Assignments

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13. Formal Reports – Catastrophic Case Assignments

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Exhibit 1 - FN Incoming Communication Sample

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Exhibit 2 - Early DM Initial Evaluation Report Sample

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Exhibit 3 - Early DM Progress Report Sample

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Exhibit 4 - Early DM Closure Report Sample

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Exhibit 5 - Task-Based Assignment Report Sample

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1. Overview. The goals of disability management (DM) are best achieved through a team approach, with the injured worker (IW), treating physician/medical provider(s), Employing Agency (EA), OWCP Claims Examiner (CE), OWCP District Office Staff Nurse (SN), and Field Nurse (FN) working together to facilitate medical recovery and successful return to work (RTW). A working relationship derived from an open and cooperative dialogue serves as a catalyst in establishing this desired team approach. FN contact and communication with the IW, treating physician/medical provider(s), EAs and other case participants are discussed in detail in Part 3 of this handbook.

This Part of the handbook is focused on the communications and documentation between the FN, SN and CE. Successful dialogue is achieved through regular and purposeful written and/or verbal communications. When determining the need for, and mode of, a communication, consideration should be given to what information needs to be communicated and whether or not the information requires immediate attention, action and/or response.

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2. Communicating with the CE. The CE is responsible for all case management decisions and actions, as well as providing nurse case management objectives, guidance and directions to the FN. Therefore, it is essential for the FN and CE to establish and maintain open lines of communication.

a. The primary mode of communicating case activity is via the scheduled submission of required formal written reports. FN reports document nurse case management activities and interventions, the outcomes of such activities and interventions, and the FN's assessment of the progress being made toward achieving the identified nurse case management goals and objectives. Formal reports are discussed in greater detail in paragraphs 7 through 10 of this Part.

b. In order for the DM process to be most effective, the FN should also confer with the CE in between the scheduled reporting periods whenever there is an issue requiring immediate attention and/or action by the CE, as discussed in paragraph 6 below. Such conferences may occur via telephone contact, email communication and/or ECOMP transmission.

c. The CE may consult with the FN to discuss specific case issues, request that the FN obtain specific medical-related information, and/or inquire about a specific medical issue.

d. When necessary, the FN should provide the CE with recommendations related to alternative interventions such as seeking a second opinion examination, referring the IW for consultation with a specialist or another type of medical provider, or referring the IW for vocational rehabilitation services.

e. The FN should confer with the CE immediately if the FN has been asked to provide medical documentation or other case-related information to a legal representative and/or agency investigative representative. See Part 10 of this handbook for details regarding the security of case information and the release of case-related information.

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3. Communicating with the SN. The SN serves not only as the administrator and coordinator of nursing services, but also as a liaison and professional resource to the FN. The SN is often able to bridge the gap between the Federal workers' compensation arena (program policies and procedures) and the medical community and/or other program stakeholders. The FN is encouraged to confer with the SN about case activities, nurse interventions, and/or OWCP/DFEC guidelines and procedures. Such communications should include, but are not limited to:

a. Conferring with the SN to discuss options and techniques for providing nurse case management services when the FN has encountered an unfamiliar situation and/or when case circumstances are prohibiting the effects of conventional nurse case management interventions;

b. Conferring with the SN to assess the appropriateness of a recommended medical treatment and/or procedure when such treatment and/or procedure is unfamiliar or considered beyond the scope of what is usual and customary for the accepted work-related injury/condition(s); and

c. Conferring with the SN to assist in communications with the CE regarding time–sensitive issues.

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4. Documenting FN Communications and Nurse Interventions. The Nurse Intervention Program (NIP) requires the FN to submit to the CE/SN particular types of communications at specified intervals during the nurse intervention phase of DM. The following paragraph focuses on the types of communications available to the FN, identifies the timing for submission of particular communications, and provides parameters regarding informational elements that should be documented within the communications. All case–related communications become part of the permanent case file record as submitted.

a. ECOMP – Employees' Compensation Operations and Management Portal - is a DFEC secure web portal that allows the FN to upload case-related documents and/or communications directly into a FECA case file. The document is viewable to the CE within 4 hours of it being uploaded in the ECOMP portal. Submission through ECOMP is the preferred method for FN transmissions of case updates/interim communications to the CE.

b. Emails are a convenient, expedient method of updating the CE/SN with time-sensitive case information. However, email transmissions require special care in the dissemination of Personally Identifiable Information (PII). The requirements regarding email communications are detailed in Part 10 of this handbook.

c. Telephonic communication may also serve as an effective means of relaying important case-related concerns and/or bringing an issue requiring immediate review and/or action to the attention of the CE/SN. The CE/SN will then document the case file with a summary of the conversation.

d. Letters sent by the FN to the IW, EA, and/or medical provider(s) are documents that are to be included as part of the official case file. It is important that all FN letters identify the nurse as a contracted nurse case management professional working as a liaison for a specific FECA claim. The case file number should be included on all FN letters.

e. Formal written reports should be formatted and typewritten and are usually submitted every 30 days from the date of FN assignment. For optimal imaging quality, it is recommended that reports be typed in a professional style type (such as Arial style) using a 12 point font.

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5. Initial Communications – Early DM Assignments. The initial update to the CE is commonly referred to as a "4 point contact", and usually occurs within 10 business days of the FN assignment date. It is a brief summary to the CE of contacts made by the FN with the IW, EA, and treating medical provider(s). The preferred mode of transmission for this update is via ECOMP transmission, but may also be accomplished via telephone contact or email communication.

a. Initial contact with the IW should include, but is not limited to:

(1) Discussion of the FN's role in the assistance of the IW's medical recovery and RTW process; and

(2) Discussion regarding the expectations of the IW's participation with the medical recovery and RTW process.

b. Initial contact with the EA (preferably with the Injury Compensation Specialist) should include, but is not limited to:

(1) Confirmation of the IW's current work status;

(2) A request for a copy of the IW's date of injury position description and the physical requirements of the job (if not already included in the case file);

(3) A determination regarding whether or not light/limited duty work accommodations are available;

(4) Discussion regarding RTW options; and

(5) Discussion to identify any barriers to the RTW process.

c. Initial contact with the treating medical provider(s) should include, but is not limited to:

(1) Obtaining the IW's current medical status and any relevant medical documentation/reports;

(2) Discussion regarding the current treatment plan and prognosis for medical recovery;

(3) Discussion regarding the IW's projected readiness for RTW, both in a light/limited duty capacity and also in a full duty capacity, and anticipated dates for such releases to work (include in this discussion the EA's ability and willingness to provide light/limited duty work accommodations during the medical recovery period); and

(4) Providing an OWCP-5 (or equivalent) for completion and submission.

d. Initial contact with the CE will include providing a brief summary of the contacts and the outcomes, and determining an appropriate case management plan based upon such.

NOTE: If the FN is unable to meet the 10 business day timeframe for completion of the 4 point contact (i.e. a treating medical provider was unavailable), s/he should notify the CE and SN immediately to advise of the delay and provide a timeframe for when the completion will occur.

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6. Interim Communications – Early DM Assignments. The CE is responsible for all case-related decisions and directions to the FN. Therefore, in addition to the formal written reports required on a monthly basis, the FN is responsible for providing interim, informal communications and updates to the CE on issues that require immediate attention or action. The preferred mode of communication for interim updates is via ECOMP transmission. However, interim communications may also be conveyed via telephone or email communication. Interim communications should be initiated when:

a. The IW refuses to speak and/or meet with the FN (or in any way obstructs nurse case management efforts);

b. A treating medical provider is unresponsive/uncooperative with nurse case management services;

c. The IW's medical/recovery status appears to have changed significantly;

d. Circumstances arise that may impede the IW's RTW efforts;

e. The IW has been released to work;

f. A job offer is made (or light/limited duty has been provided);

g. The IW refuses or accepts a job offer (or light/limited duty work);

h. The IW's work status and/or work restriction(s) change;

i. The EA is causing unnecessary delays in an otherwise viable reemployment effort;

j. The FN feels an extension of nurse services is warranted;

k. The FN feels a recommendation for vocational rehabilitation services is appropriate; and/or

l. The FN believes a recommendation for a second opinion examination is appropriate.

Exhibit 1 – FN Incoming Communication Sample - provides an example of an acceptable format for the initial and interim communications, and also incorporates the required elements.

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7. Formal Reports – Early DM Assignments. There are three types of formal reports associated with an Early DM Assignment: an Initial Evaluation Report, a Progress Report, and a Closure Report. There are informational elements common to all three report types; however, each type may have additional elements not found in the others. The paragraphs below detail these differences and provide timeframes for the submission of each report. Exhibits at the end of this Part provide examples of each report type, as referenced in the following paragraphs.

All FN reports are submitted via a secure web portal on a monthly basis, unless otherwise stipulated during the course of a case assignment. The requirements and procedures regarding the actual submission of formal reports are addressed in Part 9 of this handbook.

Each formal written report should contain the following elements of information:

a. Identification of the type of report being submitted (Initial Evaluation, Progress Report or Closure Report);

b. IW's name and case file number;

c. Dates of FN services provided for the reporting period (the date range the report is covering);

d. FN's name and contact information (telephone number and email address);

e. Items/issues requiring CE attention and/or action;

f. Work status of the IW, including the date the status was achieved (with concurrent sequencing/progression); and

g. Synopsis of nurse case management activities and contacts including, but not limited to: current medical status, contact name(s), dates of contacts, and outcomes of those contacts.

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8. The Initial Evaluation – Early DM Assignments. An Initial Evaluation is a comprehensive nursing assessment of the IW's past and present medical and work histories.

a. The Initial Evaluation Report is due within 30 days of the FN assignment date or as specified by the SN in the FN assignment/authorization letter.

b. The FN should document his/her findings related to possible barriers to the IW's medical recovery and rehabilitation as they relate to the work injury. This should include, but is not limited to: home access, mobility/potential safety issues, availability of family/community support, and/or transportation/driving considerations.

c. In addition to the elements mentioned in paragraph 7, the Initial Evaluation Report requires the following additional elements:

(1) The FN should document the specific contacts made and actions taken, including the outcome of those contacts/actions.

(2) An assessment of his/her nurse case management interventions to date: what goals were achieved, what goals were not achieved, what prevented the FN from fulfilling the goals. For example, if a work site evaluation was discussed but did not occur, the FN should document what prevented this evaluation from taking place.

(3) A FN plan of action for the next 30 days: documentation of planned nurse case management interventions and the goals to be achieved during the next reporting period (i.e. planned work site evaluations and/or attendance at medical provider appointments).

Exhibit 2 - Early DM Initial Evaluation Report Sample - provides an example of an Initial Evaluation Report which incorporates the associated required elements.

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9. The Progress Report – Early DM Assignments. A Progress Report documents case milestones, specific contacts, nurse case management activities and outcomes, an assessment of nurse interventions to date, and a plan of action. The Progress Report incorporates most of the same elements as mentioned in paragraphs 7 and 8c; however, the Progress Report should focus on the most current events of the case.

a. Progress Report documentation should reflect only information obtained and/or nurse case management activities performed during the current reporting period. The FN should not reiterate facts or actions already documented in a prior report. The exception for this relates to the documentation of the RTW status, which should reflect the work status progressively on each submitted report.

b. Dates of service for each reporting period are consecutive to the prior reporting period. The dates of service from one report to the other should not overlap.

c. A Progress Report is due every 30 days subsequent to the end date of the Initial Evaluation Report and should continue through the identified closure date.

Exhibit 3 - Early DM Progress Report Sample - provides an example of a Progress Report which incorporates the associated required elements.

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10. The Closure Report – Early DM Assignments. A Closure Report is the FN's final report for the case assignment with submission scheduled to occur based on the established nurse case management authorized timeframes and/or direction from the CE.

a. The Closure Report is due within 5 business days of the established closure date.

b. In addition to the elements documented in the paragraphs above, a Closure Report requires the following additional elements:

(1) FN recommendations to the CE related to DM actions/interventions that may assist in the forward progression and resolution of the case. For example, recommending a second opinion examination or a referral for vocational rehabilitation services.

(2) FN documentation that the IW, EA, and treating medical provider(s) were advised of the FN closure status. The FN should specify the name(s), date(s), and mode of contact for each of these communications. The FN should also submit copies of any written correspondence related to his/her closure status to OWCP for placement into the case file.

(3) FN documentation related to his/her impact on the case and achievement of established nurse case management goals and objectives.

c. Closure of FN services requires documentation and confirmation related to the disposition of case file materials using the specific language below:

By submitting this Closure Report, I certify that I have returned to DOL/DFEC or destroyed all hard copies and electronic copies of case file information for this case and any other documents that may contain Personally Identifiable Information associated with this case, in accordance with my agreement with DOL/DFEC.

Exhibit 4 – Early DM Closure Report Sample - provides an example of a Closure Report, which incorporates the associated required elements.

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11. Documenting Extension Requests – Early DM Assignments. As discussed in Part 3 paragraph 7d of this handbook, extension requests require immediate communication between the FN and the CE.

The preferred mode of communicating extension requests is via ECOMP transmission, however, email or telephonic communications may also be used. All extension requests, authorizations or denials must be documented in the case file and should include at a minimum:

a. Case file number and claimant's name;

b. Date of the communication/request/authorization/denial;

c. Name of FN and identification of the responsible CE;

d. Identification of the type of extension being requested: 30 or 60 days; and

e. Rationale as to why the extension is being requested and an explanation as to how an extension of FN services will further assist the progression and/or resolution of the case.

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12. Formal Reports – Task-Based Assignments. Task-based assignments are issued with a specific goal or objective identified. Nurse intervention is expected to be of low to moderate involvement and limited in duration. Therefore, the report(s) submitted by the FN should not be as detailed as those described in the paragraphs pertaining to the Early DM Assignment reports. However, the overall process related to documenting case updates and formal written reports remains consistent.

a. The FN should provide an initial update to the CE within 10 business days of the receipt of the assignment.

b. A formal written report should be submitted every 30 days from the date of assignment through the date of closure.

c. Interim communications should be provided to the CE via ECOMP, telephonic or email transmission.

d. The Closure Report requires documentation of appropriate dispensation of all case file materials as described in paragraph 10c.

e. Each report should contain the following specific elements:

(1) Identification of the type of Task-Based Report being submitted (i.e. Initial Report, Interim Report [as needed] or Closure Report);

(2) IW's name and case file number;

(3) FN's name, contact number and email address;

(4) Dates of service being covered in the report;

(5) Specific items/issues for CE attention and/or action;

(6) Statement of nurse case management goal(s)/objective(s) for the task-based assignment;

(7) Nurse case management actions taken to date;

(8) Outcome(s) of nurse case management actions;

(9) Identification of any barriers that may impede the FN from completing the task;

(10) Nurse case management actions planned for the next 30 days; and

(11) Documentation regarding the dispensation of case file materials (when submitting the Closure Report).

Exhibit 5 – Task-Based Assignment Report Sample - provides an example of a Task-Based Report, which incorporates the associated required elements.

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13. Formal Reports - Catastrophic Case Assignments. Catastrophic Case reporting requirements are the same as those established for Early DM Assignments. See paragraphs 5 through 11 in this Part.

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Exhibit 1 - FN Incoming Communication Sample

Date:

 

Claimant Name:

Case File Number:

FN Name:

Telephone number:

Email address:

 

1. Type of Communication:

 

_____ Initial 4 point contact

 

_____ Interim update for CE

 

2. For CE attention/action:

 

3. IW Contact:

 

4. Treating Medical Provider Contact:

 

5. EA Contact:

 

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Exhibit 2 - Early DM Initial Evaluation Report Sample

Initial Evaluation Report

Claimant Name:

Case File Number:

Date of Report:

 

Dates of Service: {from-to}

 

FN Name:

Contact Number:

Email Address:

 

For CE Attention/Action

 

Current Work Status

___ Not Working

Date IW stopped work:

 

___ Working

   

___Full time/full duty

Date status began:

 

___Full time/light duty

Date status began:

 

___Part time/light duty

Date status began:

Hours/day___

___Part time/full duty

Date status began:

Hours/day___

Work hours confirmed by: ______________

   

(name of EA representative)

   

Current work status confirmed on:

   

Injured Worker Assessment

1. General personal background information:

2. Medical history related to work injury:

3. IW goals related to medical recovery and RTW:

4. Potential barriers to medical recovery and/or RTW efforts: {ex: home environment, transportation, etc.}

5. Work history: description of duties, regular work schedule, how long in this position, prior work experience, etc.

Medical Information and Provider Contacts

6. Treating medical provider(s) information:

(Include all medical providers who are actively participating in the medical care related to the work injury.)


Name of provider:

Contact number:

Specialty:

 

Medical provider's recommendations and/or requests:

 

6a. Treatment plan obtained/date: Y___ N___

 

Submitted for file on (date):

 

6b. Medical records obtained: Y___ N___

 

7. Restrictions submitted for file on (date):

Restrictions documented/date: Y___ N___ NA ___

Form CA 17: Y___ N___

Form OWCP-5: Y___ N___

Other (explain):

Employing Agency Information and Contacts

8. EA information:

(Include the information related to each person you may have had contact with during the reporting period.)


Name of contact:

Contact number:

Position: {ICS, Duty station supervisor}

Date of contact:

8a. Date of Injury (DOI) position description obtained: Y___ N___

 

8b. Agency is able to provide light duty: Y___ N___

 

8c. Job offer requested: Y___ N___

Date:

8d. Job offer obtained and submitted for file: Y___ N ___

Date:

FN Planned Interventions for Next 30 Days

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Exhibit 3 - Early DM Progress Report Sample

Progress Report

Claimant Name:

 

Case File Number:

Date of Report:

   

Dates of Service: {from – to}

   

FN Name:

 

Contact Number:

Email Address:

   

For CE Attention/Action


   

Current Work Status

   

___ Not Working

Date IW stopped work:

 

___ Working

   

___Full time/full duty

Date status began:

 

___Full time/light duty

Date status began:

 

___Part time/light duty

Date status began:

Hrs./day___

___Part time/full duty

Date status began:

Hrs./day___

Work hours confirmed by: ______________

   

(name of EA representative)

   

Current work status confirmed on:

   

Injured Worker Contacts

(Include dates and synopsis with outcome)

Medical Information and Provider Contacts

1. Treating medical provider(s) contact(s):

(Include date(s), name of physician(s), and synopsis with outcome)

2. Restrictions submitted for file on (date):

Restrictions documented/date: Y___ N___ NA ___

Form CA 17: Y___ N___

Form OWCP-5: Y___ N___

Other (explain):

Employing Agency Information and Contacts

3. EA information:

(Include the information related to each person you may have had contact with during the reporting period.)

Name of contact:

Contact number:

Position: {ICS, Duty station supervisor}

Date of contact:

3a. Date of Injury (DOI) position description obtained: Y___ N___

 

3b. Agency is able to provide LD: Y___ N___

 

3c. Restrictions submitted for EA review on (date)

 

3d. Medical documentation re: RTW submitted to EA on (date):

 

3e. Job offer requested: Y___ N___

Date:

3f. Job offer and submitted for CE review: Y___ N ___

Date:

3g. Job site evaluation performed: Y___ N___

 

Date:

Outcome:

3h. If job site evaluation not performed, rationale for why it was not done:

 

FN Assessment of interventions performed during this reporting period

(Include a review of planned goals and objectives, if they were met; if not met, what prevented them from being met.)

FN Planned Interventions for Next 30 Days

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Exhibit 4 - Early DM Closure Report Sample

Closure Report

Claimant Name:

 

Case File Number:

Date of Report:

   

Dates of Service: {from – to}

   

FN Name:

 

Contact Number:

Email Address:

   

Recommendation(s) to the CE for continued management of this case

Second Opinion Exam: Y___ N___

   

Type of Specialist:

   

Issues for consideration:

   

Referral for vocational rehabilitation services: Y ___ N ___

Restrictions documented/date: Y___ N___

   

Form CA 17: Y___ N___

Form OWCP-5: Y___ N___

Other (explain):

Restrictions permanent: Y ___ N ___

   

Restrictions submitted for file (date):

   

Other:

   

Current Work Status

___ Not Working

Date IW stopped work:

 

___ If not working, date that physician estimates release to work:

___ Working

___Full time/full duty

Date status began:

 

___Full time/light duty

Date status began:

 

___Part time/light duty

Date status began:

Hrs./day___

___Part time/full duty

Date status began:

Hrs./day___

Work hours confirmed by: ______________

(name of EA representative)

   

Current work status confirmed on:

1. Reason for closure:

___ Time Expired

___ 120 days, No RTW

___ No extension
___ With 30 day extension.
___ With 60 day extension.
___ Other

___ RTW Monitoring completed

___ 30 day follow up
___ 60 day follow up

___ Closed per instruction of CE

2. RTW meeting conducted: Y___ N___

2a. Individuals present during the RTW meeting:

2b. Outcome of RTW meeting:

3. FN impact on this case:

4. Disposition of case file records and materials:

By submitting this Closure Report, I certify that I have returned to the DOL/DFEC or destroyed all hard copies and electronic copies of case file information for this case and any other documents that may contain Personally Identifiable Information associated with this case, in accordance with my agreement with the DOL/DFEC.

___ All records destroyed by FN.

___ All records returned to DFEC via traceable route.

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Exhibit 5 - Task-Based Assignment Report Sample

Task-Based Assignment Report

Initial Report ___

Interim Report ___

Closure Report ___

Claimant Name:

Case File Number:

Date of Report:

Dates of Service: {from – to}

FN Name:

Contact Number:

Email Address:

For CE Attention/Action

1. Goals and objectives for the task assignment:

2. FN action(s) taken to date:

3. Outcome of FN actions:

4. FN action(s) planned for the next 30 days:

5. Barrier identified to achieving stated goals and objectives:

6. Closure (if submitting final report) – Disposition of case file materials:

By submitting this closure report, I certify that I have returned to the DOL/DFEC or destroyed all hard copies and electronic copies of case file information for this case and any other documents that may contain Personally Identifiable Information associated with this case, in accordance with my agreement with the DOL/DFEC.

___ All records destroyed by FN.

___ All records returned to DFEC via traceable route.

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