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Section 3b the c84 form which is the request for temporary total compensation this is the next most frequently completed BWC form we will now discuss this form in depth highlight the pertinent sections and include information regarding vocational rehabilitation please print the form to review as I discuss it the CD for request for temporary total compensation is the form utilized to request injured worker wage compensation this is a two-part form which requires completion by both the physician of record or treating physician and the injured worker this form is required if the injured worker is temporarily totally disabled and unable to work it allows him or her to receive wages from BWC page 2 begins the physician portion of the form that must be completed it is to be completed as specifically as possible listing the following pertinent information item 7 what was the injured workers position of employment at the time of injury is the injured worker able to return to this position of employment please specify what the position of employment was and whether or not the injured worker is physically capable of returning to this position if not please mark the appropriate box if so will it be full duty light or modified duty or a gradual return to work please note if you have not received a detailed job description contact the BWC customer service team managed care organization or the self-insuring employer item 8 lists icd-9 codes with narrative diagnosis diagnosis for allowed conditions being treated which prevent the injured worker from returning to work please list all the icd-9 codes with narrative diagnosis or diagnosis for other allowed conditions being treated item 9 disability dates due to the work-related injury or disease what are the dates the injured worker will be unable to work because of his injury return to work date the actual date the injured worker is released by the physician of record to return to work or the date the worker actually went back to work estimated is the date the physician of record anticipates the injured worker may be able to return to work item 10 the following clinical findings form the basis for my recommendations please probjective and subjective findings to support your conclusions item 11 has the work-related injury or disease reached a treatment plateau at which no fundamental functional or physiological change can be expected despite continuing medical or rehabilitative intervention meaning maximum medical improvement baseless on your clinical findings what barriers exist to prevent normal recovery or maximum medical improvement item 12 is the injured worker candidate for vocational rehab services focusing on return to work do you think the injured worker is a feasible candidate for vocational rehabilitation services which focus on return to work vocational rehab services pra variety of interventions to help the injured worker return to work at the original job if that is not possible other strategies including skill training and job search assistance may.