Fill and Sign the Recommended Nursing Papers Page 2 of 1118 My Form

Vocational Rehabilitation Plan Job Search Contacts Claim number Other Will call Name of employer Description of job for which you applied/obtained Method of contact (check all that apply) Result of contact Hired Contact person/title Date of contact Address Telephone number( ) In person E-mail/Internet Regular mail Fax Submitted resume’ Telephone Were you granted an interview? Did you fill out anapplication? Not presently hiring Interview scheduled City State ZIP code BWC-2960 (Rev. 12/11/08) RH-10 Yes No Yes No Comments I have reviewed this information with injured worker Field case manager: Date: Job placement specialist: Date: OFFICIAL USE ONLY Other Will call Name of employer Description of job for which you applied/obtained Method of contact (check all that apply) Result of contact Hired Contact person/title Date of contact Address Telephone number( ) Were you granted an interview? Did you fill out anapplication? Not presently hiring Interview scheduled City State ZIP code Yes No Yes No Comments Other Will call Name of employer Description of job for which you applied/obtained Method of contact (check all that apply) Result of contact Hired Contact person/title Date of contact Address Telephone number( ) Were you granted an interview? Did you fill out anapplication? Not presently hiring Interview scheduled City State ZIP code Yes No Yes No Comments Other Will call Name of employer Description of job for which you applied/obtained Method of contact (check all that apply) Result of contact Hired Contact person/title Date of contact Address Telephone number( ) Were you granted an interview? Did you fill out anapplication? Not presently hiring Interview scheduled City State ZIP code Yes No Yes No Comments Injured worker signature Date Warning: I have answered the forgoing questions truthfully and completely. I am aware that any person who knowingly makes a false statement, misrepresentation, concealment of fact or any other act of fraud to obtain compensation as provided by BWC or self-insuring employers, or who knowingly accepts compensation to which that person is not entitled is subject to felony criminal prosecution and may, under appropriate criminal provisions, be punished by a fine or impr\ isonment or both. I hereby request payment of living maintenance benefits for the period listed and certify I have contacted each potential employer and the information listed on this job search form is correct to the best of my knowledge. Injured worker name \ Job search for week of From \ To In person E-mail/Internet Regular mail Fax Submitted resume’ Telephone In person E-mail/Internet Regular mail Fax Submitted resume’ Telephone In person E-mail/Internet Regular mail Fax Submitted resume’ Telephone Instructions • Use this form when requesting living maintenance compensation. • BWC requires you to report all earnings, including checks, cash or other\ remuneration, from any type of work activity or employment, including fu\ ll-time, part-time, self-employment or commission work. • You must provide all information requested for each job contact. Failure \ to complete the form in full could result in reductions in the benefit payable. • Please attach verifications of Internet contacts to this form. • Complete this form weekly. You should use more than one form for each week. • Submit your forms to your field case manager or job placement speciali\ st each week. • If your employer is self-insured, mail your completed form(s) to your \ self-insuring employer. Number of miles traveled Number of miles traveled Number of miles traveled Number of miles traveled