Free WKC-10146.PDF - Wisconsin

NOTIFICATION OF VOCATIONAL SERVICES by Private Rehabilitation Specialist
Return completed copy: One to insurance company (or self-insured employer) and one copy to Worker's Compensation Division.
Personal information you provide may be used for secondary purposes [Privacy Law, s. 15.04(1)(m)].

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/ e-mail: [email protected]

WC Claim Number Social Security Number Injury Date Employer Name Diagnosed Disability/Injury

Employee Name Employee Address (Number, Street, City, State, Zip Code) Date of Birth Telephone Number ( )

EMPLOYEE

Employee's Work Restrictions/Limitations Insurance Company Mailing Address (Number, Street, City, State, Zip Code) Claim Representative Name WCD Certification Number Agency Name Mailing Address (Number, Street, City, State, Zip Code) Telephone Number ( ) Telephone Number ( )

INSURER

VOCATIONAL REHABILITATION SPECIALIST

Check Services Planned:

Vocational Evaluation Retraining Plan Development

Job Placement Other (Describe) _____________________________

This is notification that I have been selected by the above-named individual to provide necessary vocational rehabilitation services to help that individual return to work.
Vocational Rehabilitation Specialist Signature Date Case Opened

Preparer Printed Name

Date Case Prepared

WKC-10146 (R. 07/2001)