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