Employer/Trainer's Report Instructions • Please print or type. • Make sure to enter four digits for the year in all date fields. • Please rate injured worker by marking the appropriate boxes below, and record observations for each item checked. • Follow the distribution list at the bottom. Injured worker Name of training facility Name of trainer Claim number Type of training Period of report Present skill level Beginning Intermediate Advanced Above average From: Average Below average To: Observations General progress Ability to follow instructions Initiative Attitude Safety habits Use of tool or equipment Manual dexterity Study habits (if applicable) 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 which the trainee was scheduled to work but did not report. Date: Month/day Year Number of hours Warning: Any person who obtains compensation from BWC or self-insuring employers by knowingly misrepresenting or concealing facts, making false statements or accepting compensation to which he/she is not entitled, is subject to felony criminal prosecution for fraud. Evaluator signature and title Date Distribution: BWC claim file, injured worker, injured worker representative, employer, employer representative BWC-2955 (Rev. 10/08/08) RH-5 American LegalNet, Inc. www.FormsWorkflow.com