Reemployment Status Review Form
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Reemployment Status Review Form. This is a Florida form and can be use in Workers Comp.
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Tags: Reemployment Status Review Form, DWC-22, Florida Workers Comp,
FOR CARRIER’S DATE STAMP
SENT TO DEPARTMENT
DEPARTMENT OF EDUCATION
BUREAU OF REHABILITATION AND REEMPLOYMENT SERVICES
2728 CENTERVIEW DRIVE, 101A FORREST BUILDING
TALLAHASSEE, FLORIDA 32399-0400
REEMPLOYMENT STATUS REVIEW FORM
1. Injured Employee Name
4. Person Completing The Review
2. Social Security Number
5. Date Of Review (MM/DD/YY)
3. Date Of Accident (MM/DD/YY)
6. Telephone Number of Person Completing Review
(
7. A) Carrier/TPA Address
)
8. A) Carrier Code
8. B) Fein#:
9. A) SC/TPA Code:
9. B) Fein#
7. B) Zip Code
10. Provide a detailed narrative explanation of the likelihood that this injured employee will return to work. Factors to
consider include, but should not be limited to: employee’s age, educational level, job of injury, prior work
experience, type of injury, treatment, medical prognosis, average weekly wage, an employers’ commitment to
rehire, etc.
11. Should the injured employee be referred to the Department’s Reemployment Services program for help with
placement or possible training and education?
yes
no
12. Date Referred to the Department: _____________________
Form DWC-22, Rev. 05/05/04
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