Fill and Sign the Wkc 6743 Vocational Expert Report This Form is Used to Establish Loss of Earning Capacity

Vocati onal 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. *Provision of your Social Security Number (SSN) is voluntary. Failure to provide it may result in an information processing delay. Personal information you provide may be used for secondary purposes [Privacy Law, s. 15.04 (1)(m), Wisconsin Statutes]. WC Claim Number Employee Name Employee Birth Date Employee Social Security Number * Employer Name Date of Accident or First Illness Highest Level of Formal Educatio n 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 o f Injury If surgery, give type Resulting physical or mental limitations based on medical or chiropractic opinion: W eekly wage at time of injury $ Present wage for com parable work with same employer $ Types of e mployment now available given age, education, work history, and physical and mental limitations of employee: WKC -6743 (R. 06/2017) Continue on reverse side Department of Workforce Development Worker’s Compensation Division 201 E. Washington Ave., Rm. C100 P.O. Box 7901 Madison, WI 53707 -7901 Telephone: (608) 266 -1340 Fax: (608) 267 -0394 http:// dwd.wisconsin .gov /wc e-mail: DWDDWC@dwd.wisconsin.gov Pay rates for types of employment listed in previous question for the genera l locality If presently employed, identify the following: Employer: Pay Rate: $ Nature of W ork Performed: Date Started: Percent of loss of earni ng 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 clas sified 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 d egree that such disabi lity 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 vocational ly rehabilitated. A person may be classified as permanently totally disabled when by reason of his or her physical or mental condition he or sh e can perform no services other than those which are so limited in quality, dependability, or quantity that a reasona bly 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(i es), and date(s) W ork History: Expert Signature Expert Name (print or type)