REPORT ON REHABILITATION Michigan Department of Labor & Economic Growth Workers’ Compensation Agency PO Box 30016, Lansing, MI 48909 INSTRUCTIONS: Reports are due 3 months from date of injury and every 4 months thereafter. All reports are to be accompanied by a current medical report. For further details, refer to R408.45(1) of the Workers’ Disability Compensation Act and Rules of Practice. Part A Employee Social Security # Employer Date of Injury Part B – If applicable, complete and proceed to Part E 1. Employee returned to work on (If a final Form WC-701 has been submitted, filing of this form is not required.) 2. Month Day Year Employee is expected to return to work on Part C – Complete if Part B above does not apply 3. Employee is unlikely to be able to return to work. If so, further action is required. Target Date Month Day Year Indicate type of action to be taken and target date of such action. Please be specific. (e.g., consultative medical examination, vocational rehabilitation evaluation, etc.) Part D – If a vocational rehabilitation referral has been made, please complete the following: Facility/Individual’s Name State Approved Provider ID # Street or PO Box City State ZIP Code State ZIP Code Part E Comments: Control Disability Costs – Invest in Early Rehabilitation Carrier or Service Company/TPA Name Claims person to whom correspondence should be sent Telephone No. (Include area code) Address (Number and Street) or PO Box City Authorized Signature Date of Report The Department of Labor & Economic Growth will not discriminate against any individual or group because of race, sex, religion, age, national origin, color, marital status, disability or political beliefs. If you need assistance with reading, writing, hearing, etc., under the Americans with Disabilities Act, you may make your needs known to this agency. WC-110 (Rev. 3/05) American LegalNet, Inc. www.USCourtForms.com