Fill and Sign the Report Workers Form

                                                                                                                                                           Wisconsin Department of Workforce Development Worker's Compensation Division 201 E. Washington Ave. Room 161 P.O. Box 7901Madison, WI 53707-7901 Telephone: (608) 266-1340 Vocational Expert Report s. 102.17(1)(d) Note: This report is for use with permanent disability caused by non scheduled injuries only. It is not to be used for scheduled injuries as described in sections 102.52 to 102.55 of the statutes which include injuries to eyes, ears, and limbs.Personal information you provide may be used for secondary purposes [Privacy Law, s. 15.04(1)(m)]. WC Claim Number Employee Name Employee Birth Date Employee Social Security Number Employer Name Date of Accident or First Illness Highest Level of Formal Education Completed Vocational Education or Training Completed Previous Employment Employer Name Mailing Address (number, street, city, state, zip code Job Duties Date Hired Date Job Terminated Employer Name Mailing Address (number, street, city, state, zip code Job Duties Date Hired Date Job Terminated List special skills affecting employee's employability List employee's preexisting physical or mental limitations Nature of Injury If surgery, give type Resulting physical or mental limitations based on medical or chiropractic opinion Weekly wage at time of injury: $ Present wage for comparable work with same employer: $ Types of employment now available given age, education, work history, and physical and mental limitations of employee WKC-6743 (R. 7/96) Continue on reverse side                                                                        Pay rates for types of employment listed in previous question for the general locality If presently employed, identify the following: Employer: Pay Rate:$ Nature of Work Performed: Date Started: Percent of loss of earning capacity to a reasonable probability due to the injury described under Nature of Injury. Give a single number percentage or a percentage range, and use the following guidelines to assist with the calculation: % A person may be classified as permanently partially disabled when by reason of his or her physical or mental condition he or she has limitations in the performance of his or her work activities. The percentage of such partial disability shall be to the degree that such disability relates to permanent total disability. The expert's opinion should include evaluation of how the disability affects this individual, having in mind his or her education, work history, training, and whether he or she can be retrained or vocationally rehabilitated. A person may be classified as permanently totally disabled when by reason of his or her physical or mental condition he or she can perform no services other than those which are so limited in quality, dependability, or quantity that a reasonably stable market for them does not exist. Factors other than those identified above that were considered in analysis (if applicable): Qualification of Expert (may attach curriculum vitae): Education : list degree(s), field of study(ies), and date(s) Work History: Expert Signature Expert Name (print or type) Expert Mailing Address (number, street, city, state, zip code) Expert Telephone Number