Fill and Sign the Rehab Services Quarterly Report for Workers Compensation Wisconsin Form

Claimant Name             Provider Name                   Denied private rehabilitation services by the carrier because             Conducting Job Search In Retraining for                   Employed (check the correct response) 2. Post injury wage       3. Post injury occupation       No longer eligible: Case fully compromised Claimant terminated relationship because Specialist terminated relationship because                                           or N Did your costs exceed the cap as determined per DWD 80.49(7)(e)? If yes, please describe what             Wisconsin Department of Workforce Development Send Completed Form To: Worker's Compensation Divisio n Rehabilitation Unit, Room C I00 P. 0. Box 7901 Madison, WI 53707-7901 Telephone: (608) 266-1340 Fax (608) 267-0394 PRIVATE VOCATIONAL REHABILITATION SERVICES QUARTERLY REPORT 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. Social Security Number Provider Number Provider Address CURRENT STATUS Please check the appropriate boxes and fill in the blanks as requested. weeks in progra m 1. Same employer, same job Same employer, different job Different employer per week 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 Hourly rate for service Number of weeks in Retraining Costs of services during or following retraining Y arrangements were made among all concerned parties to cover your fees? Signature Date