Record of Employment Contacts
Employee Name _____________________________________ Telephone No. _____________________ Address ______________________________________________________________________________ City ____________________________ State ____________________________ Zip________________ Employer _____________________________________________________________________________ Insurance Carrier _______________________________________________________________________ Date of Injury _________________________________________________________________________ This is a record of the employers contacted by the above-named employee for the week of: ____________________________________________
( month / day / year -- month / day / year )
Date of Contact
Employer Name and Address
Type of Job
Result of Contact
You may copy this form for future use in your job search or you may submit sheets in your own handwriting. A copy of your record of job search efforts should be forwarded to the workers' compensation insurance carrier or self-insured employer for its review. Be sure to include all the necessary information and make a copy for your own records. Don't forget to indicate your efforts to obtain employment through the Connecticut Job Service and/or other referral sources.