WORKERS' COMPENSATION CASE MANAGEMENT CHECKLIST TEMPLATE

Created by ChecklistGuro (https://checklistguro.com)


--- INITIAL INTAKE & ASSESSMENT ---
[ ] Employee Name
[ ] Employer Name
[ ] Date of Injury
[ ] Description of Incident
[ ] Employee ID
[ ] Body Part Affected (Head, Neck, Back, Arm, Leg, Other)
[ ] Witness Statements (if applicable)

--- MEDICAL MANAGEMENT ---
[ ] Date of Initial Medical Evaluation
[ ] Physician's Diagnosis and Treatment Plan
[ ] Number of Physical Therapy Sessions Scheduled
[ ] Uploaded Medical Report (e.g., MRI, X-ray)
[ ] Physician's Opinion on Return to Work (Full Duty, Modified Duty, No Return to Work)
[ ] Next Medical Appointment Date
[ ] Notes from Medical Provider (e.g., progress, concerns)

--- BENEFITS ADMINISTRATION ---
[ ] Claimant's Average Weekly Wage (AWW)
[ ] Benefit Payment Amount
[ ] First Benefit Payment Date
[ ] Last Benefit Payment Date
[ ] Total Benefit Payments Made
[ ] Benefit Payment Frequency (Weekly, Bi-Weekly, Monthly)
[ ] Payment Method (Direct Deposit, Check)
[ ] Benefit Payment Notes

--- COMMUNICATION & COORDINATION ---
[ ] Date of Communication
[ ] Communication Method (Phone Call, Email, Mail, In-Person Meeting)
[ ] Summary of Communication
[ ] Recipient (Injured Worker, Employer, Medical Provider, Legal Representative)
[ ] Contact Person (if applicable)
[ ] Phone Number (if applicable)
[ ] Notes/Follow-Up Actions

--- RETURN TO WORK PLANNING ---
[ ] Date of Initial Return-to-Work Discussion
[ ] Modified Duty Available? (Yes, No)
[ ] Description of Modified Duty Restrictions (if applicable)
[ ] Percentage of Work Available (if modified duty)
[ ] Scheduled Return-to-Work Date
[ ] Communication with Employer Regarding Return-to-Work Plan
[ ] Return-to-Work Plan Approved? (Yes, No)
[ ] Date of First Day Back to Work

--- LEGAL & REGULATORY COMPLIANCE ---
[ ] Claim Filing Date
[ ] State Jurisdiction (California, Texas, Florida, New York, Illinois)
[ ] Claim Number
[ ] Applicable Statute of Limitations (1 Year, 2 Years, 3 Years, Other)
[ ] Summary of Legal Review/Consultation
[ ] Date of Legal Consultation (if applicable)

--- CASE CLOSURE & FINALIZATION ---
[ ] Case Closure Date
[ ] Summary of Case Outcome & Resolution
[ ] Final Case Status (Closed - Accepted Claim, Closed - Denied Claim, Closed - Compromise Settlement, Closed - Returned to Work Full Duty, Other)
[ ] Total Benefits Paid (USD)
[ ] Case Manager Signature
[ ] Final Settlement Agreement (if applicable)
[ ] Notes Regarding Closure (e.g., outstanding issues, future considerations)

--- RECORD KEEPING & DOCUMENTATION ---
[ ] Case Notes
[ ] Document Creation Date
[ ] Scanned Documents (e.g., medical reports, correspondence)
[ ] Page Count of Case File
[ ] Document Storage Location (Physical/Digital) (Physical File, Digital Storage (Specify System))
[ ] Last File Review Date

--- END OF TEMPLATE ---
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