Free ALASKA DEPARTMENT OF LABOR - Alaska

ALASKA DEPARTMENT OF LABOR & WORKFORCE DEVELOPMENT Division of Workers' Compensation P.O. Box 107019 Anchorage, AK 99510-7019 OFFER OF ALTERNATIVE EMPLOYMENT AWCB No. INSTRUCTIONS: This form must be used if the employer in #7 below wants to offer alternative employment to the employee under AS 23.30.041(f)(1). It should accompany an Eligibility Evaluation Checklist and the evaluation report for reemployment benefits. 1. 3. Employee's Name (Last, First, Middle Initial) Address: City 7. 9. Employer: Address: City State Zip Code Telephone State Zip Code 5. Telephone: 8. 2. 4. 6. Date of Injury: Social Security No. Date of Birth:

Insurer/Adjusting Company:

10. Address: City State Zip Code Telephone

TO BE COMPLETED BY THE EMPLOYER: 11. Employer or a direct subsidiary offers alternative employment to Employee. The title of the offered job is DOT No. 12. The job is scheduled to begin on (date) ____/____/____. 13. The gross hourly wage for the job is $ 14. The job location is labor market at a comparable wage and physical demands. 16. Name of Employer/Subsidiary Representative: 18. Representative's Signature: TO BE COMPLETED BY THE REHABILITATION SPECIALIST: 20. [ ] This job is within Employee's predicted permanent physical capacities based on a physician's approval of the attached job analysis. [ ] The employee's gross hourly wage at time of injury was $ . [ ] The wage in #13 above, is equivalent to at least the state minimum wage under AS 23.10.065 or 75% of the employee's gross hourly wages at the time of injury, whichever is greater. [ ] This job prepares the Employee to be employable in other jobs that exist in the labor market as defined in AS 23.30.041(r)(3) at the required wage and within the employee's physical capacities. (Labor market documentation is attached) [ ] Employee was informed of this job offer on [ ] Employee will/will not accept this offer. 21. Name of Rehabilitation Specialist: 23. Rehabilitation Specialist's Address and Phone Number: Form 07-6151 (3/09) 22. Signature: 24. Date Mailed: . 17. Representative's Title: 19. Date Signed: . .

15. [ ] This offer of alternative employment is made in good faith because the job will prepare the employee to be employable in other jobs that exist in the