Wisconsin > Workers Comp
Private Vocational Rehabilitation Services Quarterly Report WKC-10369 - Wisconsin
| Private Vocational Rehabilitation Services Quarterly Report Form. This is a Wisconsin form and can be used in Workers Comp . |
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PRIVATE VOCATIONAL REHABILITATION SERVICES QUARTERLY REPORT Provision of your Social Security Number (SSN) is voluntary. Failure to provide it may result in an information processing delay. 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://dwd.wisconsin.gov/wc e-mail: DWDDWC@dwd.wisconsin.gov Personal information you provide may be used for secondary purposes [Privacy Law, s. 15.04(1)(m), Wisconsin Statutes]. 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 ___________________________________ Social Security Number_____________________________ Provider Name _______________________________________ Provider Number______________________________ Provider Address __________________________________________________________________________________ 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: Same job 2. Different employer Different job Post injury wage ____________________ per week Post injury occupation_________________________________________________________________________ No longer eligible, case fully compromised Claimant terminated relationship because _________________________________________________________ Specialist terminated relationship because_________________________________________________________ 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 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? No If yes, please describe what Signature: ___________________________________________________ Date Signed: ________________________ WKC-10369 (R. 12/2009) American LegalNet, Inc. www.FormsWorkFlow.com
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