Employer/Trainer's Report Injured worker Name of trainer Present skill level Beginning Intermediate Name of training facility Type of training Period of report Advanced From: To: Claim number Above average General progress Ability to follow instructions Initiative Attitude Safety habits Use of tool or equipment Manual dexterity Study habits (if applicable) Average Below average Observations Is the progress of the injured worker such that you expect he/she to continue training? Yes No Comment: Do you expect the injured worker to complete training by the scheduled completion date? Yes No Comment: Additional comments and/or recommendations: Training attendance record Please place an A in the block for any date that the trainee was scheduled to work but did not report. Date: Month/Day Year Number of hours / / / / / / / / / / / / / Warning: Any person who obtains compensation or benefits from BWC or self-insuring employers by knowingly misrepresenting or concealing facts, making false statements or accepting compensation or benefits to which he/she is not entitled, is subject to felony criminal prosecution for fraud. Trainer signature Title Date BWC-2955 (Rev. Oct. 8, 2015) RH-5 American LegalNet, Inc. www.FormsWorkFlow.com