RTW Questionaire
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.
Claimant:
Claimant No:
Total Points:
-
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)
Yes
No
Does the employer have a proven RTW program? (if unsure, click “no”)
Yes
No
Does the employer have an accurate job description? (if unsure, click “no”)
Yes
No
Has the treating physician released the IW to work?
Yes
No
Additional Comments. (e.g Reason for Decline Referral if Decline)
Decline Referral
Submit