In order to be processed and approved by the division an application must contain at a minimum:
(1) The date the employee returned to work or will return to work, and the injured employee’s name, date of injury, and Texas Department of Insurance, Division of Workers’ Compensation claim number.
(2) An employer’s statement or certification that the injured employee returned to work or will return to work in either a modified or alternative duty capacity.
(3) An employer’s statement or certification that the employer was able or will be able to sustain the employment of the injured employee as a result of the workplace modification.
(4) A copy of the division’s “Work Status Report” as provided by § 129.5 of this title (relating to Work Status Reports) from the injured employee’s 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 and additional documentation, if any.
(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) Documentation of the expenses, including receipts, that provided the workplace modification or other costs necessary to facilitate the injured employee’s return to work or the estimated costs in making those proposed workplace modifications.
(7) A signature by the employer or the employer’s authorized representative.
The provisions of this §137.47 adopted to be effective February 22, 2006, 31 TexReg 1037; amended to be effective April 25, 2010, 35 TexReg 3061.