Page of Last Name: For the Period: to: First Name: MI: WCB Case #: Name of Program or Service: Location: Activity/Result: Activity/Result: Activity/Result: 1. Participating in NYS Department of Labor's re-employment services such as One-Stop Career Centers, Workforce One, etc.: 4. Attending an accredited educational institution or licensing program to pursue employment within my work restrictions: Date of Enrollment (mm/dd/yyyy): Estimated Graduation Date (mm/dd/yyyy): Name of Educational Institution: Mailing Address: Line 2: City: State: Zip Code: Name of Career Center or Program: Mailing Address: Line 2: City: State: Zip Code: Name of Person Contacted: Daytime Phone #: Date (mm/dd/yyyy): Date (mm/dd/yyyy): Date (mm/dd/yyyy): Date(s) of Contact (mm/dd/yyyy): Result:Attach proof of enrollment.Attach supporting documentation. Use this form to show your efforts to attach to the labor market. Information regarding labor market attachment can be found on the Board's website at www.wcb.ny.gov/labor-market-attachment . Detailed instructions are on page two of this form. You can demonstrate attachment in one or more ways: 1. active participation in a job-location service such as One-Stop Career Centers, Workforce One, etc.; 2. an independent job search; 3. active participation in vocational rehabilitation through ACCES-VR, another Board approved rehabilitation program, or a job re-training program; 4. attendance in an accredited educational institution full-time to pursue employment. Check the box or boxes below to demonstrate your attachment to the labor market and provide all required information. NOTE: Benefits may be suspended if the Board issues a decision finding that your job search efforts were not sufficient. This document will be considered evidence by the NYS Workers' Compensation Board, therefore you should consult with an attorney or licensed representative before completing this form and before submitting it to the Board.Attach supporting documentation. If necessary, attach separate sheet listing additional dates and activity/result. 3. Participating in Adult Career and Continuing Education (ACCES-VR) or other rehabilitation or job-retraining programs including SUNY Educational Opportunity Centers (EOC):C-258 (5-19) www.wcb.ny.gov 2. Independent Job Search. If you conducted an independent job search complete Form C-258.1 to record your job search efforts. Be sure to complete all fields in order to show that your job search is timely, diligent and persistent. If you are only submitting a record of an independent job search, you may use Form C-258.1 without also filling out Form C-258.CLAIMANT'S RECORD OF JOB SEARCH EFFORTS/CONTACTS American LegalNet, Inc. www.FormsWorkFlow.com Page of DO NOT SCAN Section 1: Department of Labor, One-Stop, Workforce, Employment Agency etc. If you are receiving job search assistance from any of the agencies listed above, or from an individual or organization not listed, provide every date that you visited, including the orientation session, the name of the agency, individual or organization, and describe the activity or result of any visit or contact. Assistance might include use of computers, help with resume writing, interview skills, job skills classes, and meeting with an employment counselor or job coach. Note: If necessary, attach a separate sheet listing additional dates and the activity or result. Attach any written proof from your visit(s) to a job center. Section 2: Independent Job Search Check box if you completed an independent job search. Complete and submit Form C-258.1 to document your job search efforts. Section 3: Participating in Adult Career and Continuing Education (ACCES-VR) or other rehabilitation or job-retraining programs including SUNY Educational Opportunity Centers (EOC) If you were referred to ACCES-VR by a Vocational Rehabilitation Counselor, provide the date or dates that you met with an ACCES-VR counselor. Also provide the agency address, telephone number, and the name of the person you met with and the results of your meeting. Note: If you visited ACCES-VR, request an ACCES-VR contact form from your counselor and attach to Form C-258. If you participated in other vocational rehabilitation or a job retraining program including SUNY Educational Opportunity Centers (EOC) that is not listed in any other section, provide the start and end dates, as well as the name and address of the program. Note: Please provide copies of any course curriculum, certificates of participation, license applications, or other documents relating to the job retraining program and attach to Form C-258. Section 4: Attending an accredited educational institution or licensing program to pursue employment within my work restrictions If you are enrolled full-time in an accredited educational institution, provide the date of enrollment. Also provide your estimated graduation date and the name and address of the educational institution. Note: You must attach copies of the course curriculum and proof of enrollment to Form C-258. Part-time enrollment does not meet the requirements of the law necessary to show attachment to the labor market. Bring copies of all C-258 and C-258.1 forms and documents supporting your job search efforts to every hearing before the Workers' Compensation Board. If only submitting a record of an independent job search, you may use Form C-258.1 without also filling out Form C-258.www.wcb.ny.govC-258 INSTRUCTIONS (5-19) Use this form to record efforts to obtain employment within your physical restrictions through vocational service, continued education, or an independent job search. If you conducted an independent job search, also complete Claimant's Record of Independent Job Search Efforts (Form C-258.1). Note: Only complete the section(s) of this form relevant to your job search efforts. Vocational Rehabilitation Counselors at the Workers' Compensation Board are available to help you complete this form and may be able to assist you with your job search efforts. Call (877) 632-4996 and ask to speak with a Vocational Rehabilitation Counselor. Benefits may be suspended if the Board issues a decision finding that your efforts were not sufficient. This document will be considered evidence by the NYS Workers' Compensation Board, therefore you should consult with an attorney or licensed representative before completing this form and before submitting it to the Board. This form and all documents supporting your job search efforts must be submitted to the Board in advance of your hearing. Documents should be sent to the Board as follows: l You or your attorney can Fax (877-533-0337) or email (wcbclaimsfiling@wcb.ny.gov ) or eCase Document Upload at least three days before your hearing l If you are not represented by counsel, you can use one of the above described methods, or you can mail to the Board at least six days prior to the date of your hearing to PO Box 5205, Binghamton, NY 13902-5205. Write your name and WCB Case # at the top of every document.Instructions for Completing Claimant's Record of Job Search Efforts/Contacts (Form C-258) American LegalNet, Inc. www.FormsWorkFlow.com