DEPARTMENT OF EDUCATION BUREAU OF REHABILITATION AND REEMPLOYMENT SERVICES 2728 CENTERVIEW DRIVE, 101A FORREST BUILDING TALLAHASSEE, FLORIDA 32399-0400 REQUEST FOR SCREENING Mail Form to: BUREAU OF REHABILITATION AND REEMPLOYMENT SERVICES An application by any party needs completion of information in blocks 1 through 12. 1. Employee Name 2. Social Security Number 3. Date of Accident 4. Address (include apartment number, city, state, & zip code) 5. County 6. Telephone Number ( ) This section to be completed by the injured employee: I request a Department Screening and whatever services are determined appropriate to return me to suitable gainful employment. I am applying because I have talked with my employer and: Employment may be available when I am released to work with permanent restrictions. Employment within my restrictions has already been offered. My employer has told me no work is available in my same job or a modified or different job. Employee's Signature Date 7. Employer/Company Name 9. Telephone Number 8. Employer/Company Address (include city, state & zip code) ( ) 11. Carrier or SC/TPA Address (include city, state & zip code) 10. Carrier or SC/TPA Name 12. Telephone Number ( ) I believe that the above-referenced employee is entitled to a Department screening for reemployment services. Employer or Carrier Signature/ Title Date Check here if employer referral. Form DWC-23, Rev. 05/05/2004 Check here if carrier referral. American LegalNet, Inc. www.FormsWorkflow.com