Insurer-Employer Initital Reemployment Report For Injured Worker {206}

Print Form FORM 206 ­ Insurer/Employer Initial Reemployment Report for Injured Worker INSTRUCTIONS: §34A-8a-301 of the Injured Worker Reemployment Act requires insurance carriers or employers to prepare and submit this Form 206 within 30 days after it appears that: 1) an injured worker is or will be a "disabled injured worker as defined in §34A-8a-102(1) of the Act; or 2) the injured worker's temporary total disability compensation period exceeds 90 days. Within 10 days after submitting this Form 206 the insurance carrier or employer must either refer the injured worker to the Utah Office of Rehabilitation or a private rehabilitation/reemployment service; or request postponement or waiver of the referral requirement by submitting Form 215 to the Division of Industrial Accidents (IAD). The Utah Labor Commission rules and forms related to the Utah Injured Worker Reemployment Act can be found on the IAD website at http://laborcommission.utah.gov/IndustrialAccidents/index.html. PLEASE PRINT OR TYPE CONTACT INFORMATION (Please use MM/DD/YYYY for all dates) SS#: XXX - XX - ________ (last four digits only) _____/_____/_____ Employee's Full Name:__________________________________ Date of Injury _____/_____/_____ Address:______________________________________________ Date of Birth Occupation of Injured Worker: ___________________________ Employer ­ Name & Contact Information: ________________________________________________________________________________________ Insurance Carrier ­ Adjustor's Name & Contact Information (if applicable): ________________________________________________________________________________________ Rehabilitation or Reemployment Service Provider - Name & Contact Information (if applicable): ________________________________________________________________________________________ A. Reemployment Assistance is NECESSARY Check "A" if reemployment assistance is needed; also check the recommended services: Counseling Vocational Evaluation Job Placement Job Seeking Skills Reemployment Plan On the Job Training Transferable Skills Analysis Jobsite Modification Coordinate Reemployment Retraining Other: _____________________ Referral for reemployment services: Provider: ______________________ Counselor _____________________ Referral Date _____/_____/______ City:______________ State:_____ Zip:____________ Telephone Number: ( ____0_________________ Pre-Injury Weekly Wage: $__________ B. Unable to Determine Need or Proceed with Assistance Check "B" if any of the following are true; also check appropriate response below. You must submit Form 215 within 10 days to obtain IAD's approval to waive or postpone the referral. Not medically stable Physically capacity has not been determined Claim liability is under review C. Employment Assistance is NOT NECESSARY Check "C" if reemployment assistance is NOT necessary (specify reasons below): Worker returned to work (RTW): Same Employer New Employer Self Employed Same Job New Job Modified Job Worker RTW as a result of vocational rehabilitation support services Disability too severe to return to work Other (specify):__________________ Form 206 Adopted October 14, 2009 State of Utah Labor Commission Division of Industrial Accidents 160 East 300 South P.O. Box 146610 Salt Lake City, UT 84114-6610 Telephone: (801) 530-6800 Fax: (801) 530-6804 Toll Free: (800) 530-5090 www.laborcommission.utah.gov American LegalNet, Inc. www.FormsWorkFlow.com