Record of Employment ContactsEmployee NameEmployerAddressInsurance CarrierDate of InjuryThis is a record of the employers contacted by the above-named employee for the week of:( month/ day / yearmonth / day / year)Employer Name andType of JobResult of ContactReferralSourceDate of ContactAddressPhone NumberPerson ContactedYou may copy this form for future use in your job search oryou may submit sheets in your own handwriting.A copy of your record of job search efforts should be forwarded to the workers compensationinsurance carrier or self-insured employer for its review. Be sure to include all the necessaryinformation and make a copy for your own records. Don t forget to indicate your efforts toobtain employment through the Connecticut Job Service and/ or other referral sources.262000 (C) American LegalNet, Inc.