Free WKC-10369.PDF - Wisconsin

PRIVATE VOCATIONAL REHABILITATION SERVICES QUARTERLY REPORT

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 Imaging Server Fax: (608) 260-2503 Telephone: (608) 266-1340 Fax: (608) 267-0394 http://www.dwd.state.wi.us/wc/ e-mail: [email protected]

The Quarterly Report should be completed for each WC claimant receiving return to work services from the certified specialist and submitted to the WC Rehabilitation Unit by the 5th day of the months April, July, October and January of each year. Claimant Name Provider Name Provider Address ___________________________________ Social Security Number _______________________________________ Provider Number ___________________________ ____________________________

________________________________________________________________________________ CURRENT STATUS

Please check the appropriate boxes and fill in the blanks as requested. Denied private rehabilitation services by the carrier because Conducting Job Search In Retraining for ________ weeks in ______________________________________________________ program Employed (check the correct response) 1. Same employer: 2. Different employer Post injury wage ____________________ per week Post injury occupation _______________________________________________________________________ _______________________________________________________ _______________________________________________________ No longer eligible, case fully compromised Claimant terminated relationship because Specialist terminated relationship because Same job Different job ________________________________________

__________________________________________________________________________________________

CLOSURE INFORMATION Please fill in the blanks and check the appropriate box as requested. _____________ _____________ _____________ _____________ Number of days in Job Search before placement Costs of Job Search phase, and ________ Hourly rate for service Number of weeks in Retraining Costs of services during or following retraining Yes No If yes, please describe what

Did your costs exceed the cap as determined per DWD 80.49(7)(e)?

arrangements were made among all concerned parties to cover your fees? __________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________

Signature:

___________________________________________________ Date Signed:

______________________

WKC-10369 (R. 09/2001)