This questionnaire was developed to help identify challenging return to work claims. If the numeric total is 8 or more please click ‘submit’ for a No cost triage by Windham.
4 to 6 - Assistance NOT likely required.
8 to 12 - Assistance required.
Is this an acute injury? (acute injury is a broken bone, fracture, laceration, contusion or burn)
Does the employer have a proven RTW program? (if unsure, click “no”)
Does the employer have an accurate job description? (if unsure, click “no”)
Has the treating physician released the IW to work?
Additional Comments. (e.g Reason for Decline Referral if Decline)