Fill and Sign the New York Report New York Form

                                                                                     1. Claimant's occupation       Length of employment       2. Claimant's salary       Type of worker: Full time Part time Present compensation rate             6. Name, rating and address of attending doctor             Specialty       b. Has vocational rehabilitation program been arranged or instituted? Yes Date instituted       service             Signature             Title       Telephone No.       / /[ ] CARRIER'S REPORT ON REHABILITATION to Chair, Workers' Compensation Board W. C. B. CASE NUMBER CARRIER CASE NUMBER CARRIER I.D. NUMBER DATE OF ACCIDENT NAME ADDRESS APT. NO. CLAIMANT EMPLOYER INSURANCECARRIER ATTORNEY/REPRESENTATIVE 3. Is claimant's job still available? Yes No 4. Degree of disability: Total Partial 5. Present condition (include diagnosis, complaints and pre-existing impairments, if any) 7. REHABILITATION a. Has medical rehabilitation program, under the supervision of a qualified specialist, been authorized and instituted? Yes No No c. If Yes to a and/or b, give name, rating and address of specialist and/or name and address of vocational d. Is a vocational rehabilitation program recommended? Yes No e. If answer is No to a or b, and Yes to d, please explain: Claimant refused Doctor refused Attorney refused Medically unstable Other (explain) Dat e FORM R (8-05) THIS AGENCY EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION.