Rehabilitation Request
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Rehabilitation Request Form. This is a Connecticut form and can be use in Workers Compensation.
Tags: Rehabilitation Request, WCR-1, Connecticut Workers Compensation,
Rehabilitation
Request
WCR-1
Rev. 4-30-2009
State of Connecticut
Workers Compensation Commission
Rehabilitation Services
21 Oak Street, 4th Floor
Hartford, CT 06106-8011
Date filed with Rehabilitation Services
Please TYPE or PRINT IN INK
(for WCC use only)
Name
Address
Date of Injury
Date of Birth
(Number and Street
Injured Body Part
City or Town
State
City or Town Where Injured
Zip Code)
Employer at Time of Injury
I wish to receive services that will help me to return to work EMPLOYEE SIGNATURE REQUIRED:
Telephone (Area Code + Number)
Date
FOR OFFICE USE ONLY
Rehabilitation District
Compensation District
WCC File #
Comments
Referral Source
Address
Date
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