Free WKC-6743.PDF - Wisconsin

Vocational Expert Report
s. 102.17(1)(d)

Department of Workforce Development Worker's Compensation Division 201 E. Washington Ave., Rm. C100 P.O. Box 7901 Madison, WI 53707-7901 Telephone: (608) 266-1340 Fax: (608) 267-0394 http://www.dwd.state.wi.us/wc/ email: [email protected]

Note: This report is for use with permanent disability caused by non-scheduled injuries only. It is not to be used for scheduled injuries as described in sections 102.52 to 102.55 of the statutes which include injuries to eyes, ears, and limbs.
Personal information you provide may be used for secondary purposes [Privacy Law, s. 15.04(1)(m)]. WC Claim Number Employee Name Employee Birth Date

Employee Social Security Number

Employer Name

Date of Accident or First Illness

Highest Level of Formal Education Completed

Vocational Education or Training Completed

Previous Employment
Employer Name Mailing Address (number, street, city, state, zip code

Job Duties

Date Hired

Date Job Terminated

Employer Name

Mailing Address (number, street, city, state, zip code

Job Duties

Date Hired

Date Job Terminated

List special skills affecting employee's employability:

List employee's preexisting physical or mental limitations:

Nature of Injury

If surgery, give type

Resulting physical or mental limitations based on medical or chiropractic opinion:

Weekly wage at time of injury: $

Present wage for comparable work with same employer: $

Types of employment now available given age, education, work history, and physical and mental limitations of employee:

WKC-6743 (R. 07/2001)

Continue on reverse side

Pay rates for types of employment listed in previous question for the general locality:

If presently employed, identify the following: Employer: Pay Rate: Nature of Work Performed: Date Started: Percent of loss of earning capacity to a reasonable probability due to the injury described under Nature of Injury. Give a single number percentage or a percentage range, and use the following guidelines to assist with the calculation: ________________________% A person may be classified as permanently partially disabled when by reason of his or her physical or mental condition he or she has limitations in the performance of his or her work activities. The percentage of such partial disability shall be to the degree that such disability relates to permanent total disability. The expert's opinion should include evaluation of how the disability affects this individual, having in mind his or her education, work history, training, and whether he or she can be retrained or vocationally rehabilitated. A person may be classified as permanently totally disabled when by reason of his or her physical or mental condition he or she can perform no services other than those which are so limited in quality, dependability, or quantity that a reasonably stable market for them does not exist. $

Factors other than those identified above that were considered in analysis (if applicable):

Qualification of Expert (may attach curriculum vitae): Education: list degree(s), field of study(ies), and date(s)

Work History:

Expert Signature

Expert Name (print or type)