[ TO CHAIR, WORKERS' COMPENSATION BOARD This report shall be submitted within 30 days after the earliest of the following dates: a. Date on which lost time (intermittent or continuous) exceeds 12 weeks; or b. Date on which rehabilitation services were instituted or arranged. WCB CASE NUMBER CARRIER CASE NUMBER CARRIER I.D. NUMBER ] CARRIER'S REPORT ON REHABILITATION DATE OF ACCIDENT CLAIMANT'S SOC. SEC. NO. CLAIMANT'S TELEPHONE NO. CLAIMANT'S DATE OF BIRTH DATE LOST TIME BEGAN NAME CLAIMANT EMPLOYER INSURANCE CARRIER ATTORNEY/ REPRESENTATIVE ADDRESS 1. Claimant's occupation .................................................................................... Length of employment ...................... 2. Claimant's salary ......................Type of worker: Full time Part time Present compensation rate ..................... 3. Is claimant's job still available? Yes No 4. Degree of disability: Total Partial 5. Present condition (include diagnosis, complaints and pre-existing impairments, if any) ............................................... ......................................................................................................................................................................................... 6. Name, rating and address of attending doctor ............................................................................................................... ............................................................................................................................... Specialty ........................................ 7. REHABILITATION a. Has medical rehabilitation program, under the supervision of a qualified specialist, been authorized and instituted? Yes No b. Has vocational rehabilitation program been arranged or instituted? Yes Date instituted .......................... No c. If Yes to a and/or b, give name, rating and address of specialist and/or name and address of vocational service ........................................................................................................................................................................ d. Is a vocational rehabilitation program recommended? Yes No e. If answer is No to a or b, and Yes to d, please explain: Claimant refused Doctor refused Attorney refused Medically unstable Other (explain) ...................................................................................................................................................... ...................................................................................................................................................... Signature _______________________________________________ Date _______________________________ Title ___________________________________________________ Telephone No. ________________________ FORM R (8-05) THIS AGENCY EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION. American LegalNet, Inc. www.USCourtForms.com