Fill and Sign the Workers Compensation Forms List Wisconsin Department of

NOTIFICAT ION OF VOCATIONAL SERVICES by Private Rehabilitation Specialist Return completed copy: One to insurance company (or self -insured employer) and one copy to Worker’s Compensation Division. *Provision of your Social Security Number (SSN) is voluntary . Failu re 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]. EMPLOYEE WC Claim Number Employee Name Social Security Number * Employee Address (Number, Street, City, State, Zip Code) Injury Date Date of Birth Telephone Number ( ) Employer Name Diagnosed Disability/Injury Employee’ s Work Restrictions/Limitations INSURER Insurance Company Mailing Address (Nu mber, Street, City, State, Zip Code) Claim Representative Telephone Number ( ) VOCATIONAL REHABILITATION SPECIALIST Name (Please print) WCD Certification Number Telephone Number ( ) Agency Name Mailing Address (Number, Street, City, State, Zip Code) Check Services Planned: Vocational Evaluation Job Placement Retraining Plan Development Other (Describe) : _____________________________ This is not ification that I have been selected by the above -named individual to provide necessary vocational rehabilitation services to help that individual return to work. Vocational Reha bilitation Specialist Signature Date Case Opened WKC -10146 (R. 06/20 17) 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