An employer must provide the following information on the application to be considered for reimbursement from the account:

1. (1) The date the employee returned to work, and if available, the injured employee's Texas Department of Insurance, Division of Workers' Compensation claim number.
2. (2) A statement or certification that the injured employee returned to work in either a modified or alternative duty capacity.
3. (3) A statement or certification that the employer was able to sustain the employment of the injured employee as a result of the workplace modification.
4. (4) A copy of the Division's "Work Status Report" from the injured employee's examining doctor that specifies the injured employee's physical restrictions or limitations, which necessitated the provision of a workplace modification in order for the employee to return to work in a modified or alternative duty capacity.
5. (5) A detailed description of the workplace modification, including any supporting information such as receipts, photos or diagrams of the modification, and how the modification facilitates the doctor-identified physical restrictions or limitations.
6. (6) Documentation of the expenses that provided the workplace modification or other costs necessary to facilitate the injured employee's return to work.

Source Note:The provisions of this §137.47 adopted to be effective February 22, 2006, 31 TexReg 1037.