Understanding the Washington Activity Prescription Form (APF)

The Form That Starts the Clock

A fax lands on your desk at 2:47 p.m. on a Thursday. It is two pages, partially legible, from an occupational medicine clinic — the Activity Prescription Form for a warehouse picker who strained his lower back on Tuesday. You have had this worker for six years. You also have a Stay-at-Work reimbursement application pending for a different claim.

What happens next with that form determines whether you place this worker in a compliant transitional role within days, whether your light-duty job description gets the attending provider's written approval in time, and ultimately whether that day of light-duty work is reimbursable under Washington's Stay-at-Work program. The APF is not just a physician document. It is the input for your entire RTW workflow — the job description, the duty match, the offer letter, the reimbursement application, and the file documentation.

This article walks through each section of the Washington Activity Prescription Form, explains what it is telling you, and maps each field to the employer action it triggers.

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What the APF Is and Why It Exists

The Activity Prescription Form is a Washington L&I standardized form completed by the worker's attending provider — the treating physician, physician assistant, or ARNP authorized to manage the claim. Its purpose is to communicate the worker's functional capacity and work restrictions in a structured, consistent format that both the claim manager and the employer can act on.

The form is not a narrative note or a letter. It uses checkboxes, pound limits, and hour limits organized by body movement and position. That structure exists precisely so an employer can translate the restrictions into job task language without calling the clinic to interpret a handwritten paragraph.

Washington L&I controls the form version. Confirm the current version number and effective date with WA L&I before using any copy in your program — the form is periodically revised, and the version on your clinic's fax template may lag the current release. Verify at lni.wa.gov or by contacting L&I's medical unit directly.

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Reading the APF Section by Section

The form is organized into sections that move from administrative information to functional limits to the provider's authorization and next-appointment date. Here is how each section maps to your workflow.

Section A — Worker and Claim Identification

This section carries the worker's name, date of birth, claim number, employer name, date of injury, and the treating provider's information. Before you read a single restriction, confirm that:

1. The claim number on the form matches your TPA's or L&I's file number. A transposed digit means the restriction window that follows applies to a different claim.
2. The date of exam matches or follows the date of injury. An APF dated before the injury is a data-entry error that will surface in a reimbursement audit.
3. The employer name matches your legal entity name as it appears on the claim. If you have multiple entities, mismatches create filing ambiguity.

Flag any discrepancy before you build a job description from this form. Correcting a claim number after a Stay-at-Work application is submitted requires amended filings.

Section B — Work Status

This is the binary decision point. The provider checks one of three statuses:

• Full duty, no restrictions — no further employer action required from a restriction standpoint. Document receipt, close the intake for this date.
• Modified/transitional duty with restrictions — your job description and duty-matching process begins here.
• Cannot work at this time — document receipt; notify your claim manager; no transitional assignment is possible until a subsequent APF changes this status.

A "modified duty" status without a completed restrictions section is ambiguous. Contact the clinic through your established intake process to request a complete form before building a job description — do not interpret a partial form as unrestricted.

Section C — Physical Restrictions

This is the operational core of the washington activity prescription form. Section C typically covers:

Restriction Category	What It Specifies	Employer Action
Lifting/carrying	Maximum pounds and frequency (occasional / frequent / continuous)	Set pound limits in your job description; match to tasks at or below limit
Pushing/pulling	Maximum force or "avoid"	Identify or eliminate push/pull tasks in candidate duties
Reaching (above shoulder, at waist, below waist)	Allowed / restricted / avoid	Match workstation height and task type
Sitting / standing / walking	Hours per shift or "as tolerated"	Specify in the job description; note alternating-position requirements
Bending/stooping/squatting	Frequency limits or avoid	Review each candidate task for postural demand
Hand/wrist/grip	Dominant vs. non-dominant; frequency	Relevant for production, keyboard, or tool-use duties
Driving	Allowed / restricted (includes operating equipment)	Critical for transportation, delivery, or forklift roles

Every field you leave unaddressed in your job description is a field that can produce an ineligible day under the Stay-at-Work program or a compliance gap in a later audit. Map each restriction to an explicit statement in your light-duty job description — not a general "light duty as directed" line.

Section D — Hours of Work

The provider specifies the approved number of hours per day and days per week. This is not a suggestion. Under WA L&I's Stay-at-Work rules, a day worked outside the approved hours is ineligible for reimbursement — for example, if the APF authorizes four hours and the worker works six hours that day, that day does not qualify. (WA L&I Complete Stay at Work Guide, 2024)

Build the approved schedule directly into the transitional job description and communicate it to the worker's supervisor in writing. A supervisor who keeps a worker two hours late — even with the worker's agreement — can disqualify that day from reimbursement without either party realizing it.

A partial day worked within approved hours counts as one reimbursable day under Stay-at-Work rules. (WA L&I Complete Stay at Work Guide, 2024) Document the actual hours worked each day regardless, both for audit readiness and for tracking the 120-day reimbursement window.

Section E — Provider Authorization, Next Appointment, and Signature

Three items in this section drive your calendar and your Stay-at-Work file:

1. Written provider approval of the transitional job description. The attending provider must approve your transitional job description in writing before or concurrent with the worker beginning light duty. (WA L&I Complete Stay at Work Guide, 2024) The APF itself is not that approval unless the provider has reviewed and signed off on your specific job description — which is a separate document. Submit your light-duty job description to the provider as early as possible; delays in provider approval delay the start of eligible days and reduce your reimbursement window. (WA L&I, 2025)

2. Next appointment date. Mark this date in your RTW tracking system. The restrictions on the current APF are valid until the next exam produces a new APF. If the next appointment date passes without a new form, contact your claim manager — a lapsed APF means you are operating without current restriction documentation.

3. Signature and date. An unsigned APF has no legal standing as a restriction document. Do not build a job description from an unsigned form.

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From APF to Job Description: The Translation Step

The restrictions in Section C are written in clinical language — "occasional lifting to 20 lbs," "no overhead reaching." Your transitional job description must convert those clinical parameters into task statements that a supervisor can enforce and that a WA L&I auditor can verify against the APF.

The translation process looks like this:

1. Pull each restriction from Section C and Section D.
2. For each candidate transitional task, write a specific task statement that stays within the restriction: "Inspect incoming parts at a seated workstation; no lifting above 15 lbs; no reaching above shoulder height."
3. Review the full list of tasks against the restrictions for any gap. If a task requires something the APF restricts — even incidentally — remove it or modify it.
4. Submit the completed job description to the attending provider for written approval before the worker's first day in the role.

For detailed guidance on building the job description itself, see the light-duty job description guide. For how transitional task options connect to occupation-based task libraries, see the article on O*NET-based duty matching.

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APF Receipt and the Stay-at-Work Filing Clock

Washington's Stay-at-Work program reimburses 50% of the worker's base wages for up to 120 days worked in a transitional role, with a maximum reimbursement of $25,000 per claim for injuries on or after January 1, 2025. (AGC of Washington, 2025) The reimbursement application must be submitted within one year after the light-duty work is completed. (WA L&I, 2025) No reimbursement is available after claim closure, and no reimbursement applies to dates worked more than one year before the application date. (WA L&I Complete Stay at Work Guide, 2024)

The APF receipt date starts your documentation chain. Every reimbursable day requires:

• A valid APF on file covering that date.
• A provider-approved transitional job description on file.
• Documented actual hours worked within the approved schedule.
• The worker performing tasks within the approved job description.

A day worked outside any one of those four conditions is ineligible — not just reduced, but disqualified. (ERNwest, 2025) That is why APF intake is not a passive filing step. It is the foundation of your reimbursement record.

For a full walkthrough of the reimbursement application process, deadlines, and eligibility criteria, see the Washington Stay-at-Work reimbursement guide.

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Common APF Intake Mistakes and How to Avoid Them

Mistake	Consequence	Prevention
Filing the APF without reviewing Section D hours	Worker placed in excess of approved hours; days disqualified from reimbursement	Read hours before communicating schedule to supervisor
Treating the APF as provider job-description approval	Ineligible days; audit finding	Obtain a separate written provider sign-off on the specific job description
Using an outdated APF after the next-appointment date passes	Restriction documentation gap	Calendar all next-appointment dates; chase the updated APF proactively
Accepting an unsigned or undated form	No valid restriction record	Return for signature before building a job description
Missing the one-year reimbursement filing window	Forfeited SAW reimbursement	Track light-duty end date; set a filing-deadline reminder at light-duty start

For broader guidance on building a repeatable intake process across all incoming restriction forms, see restriction intake best practices.

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Systematizing APF Management

A single APF for a single claim is manageable in a spreadsheet. Two concurrent claims with different restriction windows, different provider appointment cycles, and different transitional job descriptions — each requiring its own Stay-at-Work documentation chain — is where ad hoc systems break down. The operational risk is not misreading one field; it is losing track of which version of the APF is current for which claim, or missing a filing deadline because the next-appointment date was never entered anywhere.

RTW case-management software designed for the employer side maintains the restriction window, the approved hours, the job description version, and the reimbursement filing deadline in a single case record — so that a second claim opening does not push the first one's deadline off your screen.

If your current process relies on a shared drive folder and a spreadsheet, the Work Restriction Intake & Physician Communication Kit provides structured templates for APF intake logging, provider communication, and job description approval tracking — the paper layer that supports a compliant SAW reimbursement file.

The APF tells you what the worker can do. Your documentation tells the auditor that you acted on it correctly.

Confirm all specific form version numbers, effective dates, and program thresholds with WA L&I before implementing or updating your intake process. Requirements and form versions change; what is current here should be verified at lni.wa.gov.