Free FORM - Connecticut

Rehabilitation Request
Name Date of Birth

State of Connecticut Workers Compensation Commission Rehabilitation Services 21 Oak Street, 4th Floor Hartford, CT 06106-8011
Please TYPE or PRINT IN INK

WCR-1
Date filed with Rehabilitation Services
(for WCC use only)

Injured Body Part

Address

(Number and Street

City or Town

State

Rev. 4-30-2009

Zip Code)

Date of Injury

City or Town Where Injured

Employer at Time of Injury

I wish to receive services that will help me to return to work EMPLOYEE SIGNATURE REQUIRED:

Telephone (Area Code + Number)

Date

FOR OFFICE USE ONLY
Rehabilitation District Compensation District WCC File # Comments

Referral Source

Address

Date