0LFKLJDQ 'HSDUWPHQW RI /icensing and Regulatory Affairs :RUNHUV¶ &RPSHQVDWLRQ $JHQF\ 32 %R[ /DQVLQJ 0, ,16758&7,216 5HSRUWV DUH GXH PRQWKV IURP GDWH RI LQMXU\ DQG HYHU\ PRQWKV WKHUHDIWHU All reports are to be accompanied by a current medical report. )RU IXUWKHU GHWDLOV UHIHU WR 5 RI WKH :RUNHUV¶ 'LVDELOLW\ &RPSHQVDWLRQ $FW DQG 5XOHV RI 3UDFWLFH REPORT ON REHABILITATION Part A Employee Employer Social Security # Date of Injury Part B ­ If applicable, complete and proceed to Part E 1. 2. (If a final Form WC-701 has been submitted, filing of this form is not required.) Employee returned to work on 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. Please be specific. (e.g., consultative medical examination, vocational rehabilitation evaluation, etc.) Indicate type of action to be taken and target date of such action. Month Target Date Day Year Part D ­ If a vocational rehabilitation referral has been made, please complete the following: State Approved Provider ID # City State ZIP Code Facility/Individual's Name Street or PO Box Part E Comments: Control Disability Costs ­ Invest in Early Rehabilitation Carrier or Service Company/TPA Name Claims person to whom correspondence should be sent Address (Number and Street) or PO Box Authorized Signature Telephone No. (Include area code) City Date of Report State ZIP Code LARA is an equal opportunity employer/program. Auxiliary aids, services and other reasonable accommodations are available upon request to individuals with disabilities. WC-110 (Rev. 11/11) American LegalNet, Inc. www.FormsWorkFlow.com