Vocational Rehabilitation Plan Job Search Contacts Injured worker name Job search for week of Instructions • Use this form when requesting living maintenance compensation. • BWC requires you to report all earnings, including checks, cash or other remuneration, from any type of work activity or employment, including full-time, part-time, self-employment or commission work. • You must provide all information requested for each job contact. Failure to complete the form in full could result in reductions in the benefit payable. Name of employer From Claim number To • Please attach verifications of Internet contacts to this form. • Complete this form weekly. You should use more than one form for each week. • Submit your forms to your field case manager or job placement specialist each week. • If your employer is self-insured, mail your completed form(s) to your self-insuring employer. Address City Description of job for which you applied/obtained Contact person/title Method of contact (check all that apply) Telephone In person E-mail/Internet Fax Comments Did you fill out an application? Regular mail Submitted resume’ Yes State No Date of contact Were you granted an interview? Yes Result of contact Hired Not presently hiring City Description of job for which you applied/obtained Contact person/title Method of contact (check all that apply) Telephone In person E-mail/Internet Fax Comments Did you fill out an application? Regular mail Submitted resume’ Yes State No Were you granted an interview? Yes Result of contact Hired Not presently hiring Contact person/title Method of contact (check all that apply) Telephone In person E-mail/Internet Fax Comments Did you fill out an application? Regular mail Submitted resume’ Yes State No Were you granted an interview? Yes Result of contact Hired Not presently hiring Contact person/title Method of contact (check all that apply) Telephone In person E-mail/Internet Fax Comments Did you fill out an application? Regular mail Submitted resume’ Yes State No Will call Other Interview scheduled Number of miles traveled No City Description of job for which you applied/obtained Telephone number ( ) ZIP code Date of contact Name of employer Address Will call Other Interview scheduled Number of miles traveled No City Description of job for which you applied/obtained Telephone number ( ) ZIP code Date of contact Name of employer Address Will call Other Interview scheduled Number of miles traveled No Name of employer Address Telephone number ( ) ZIP code Telephone number ( ) ZIP code Date of contact Were you granted an interview? Yes Result of contact Hired Not presently hiring Will call Other Interview scheduled Number of miles traveled No Warning: I have answered the forgoing questions truthfully and completely. I am aware that any person who knowingly makes a false statement, misrepresentation, concealment of fact or any other act of fraud to obtain compensation as provided by BWC or self-insuring employers, or who knowingly accepts compensation to which that person is not entitled is subject to felony criminal prosecution and may, under appropriate criminal provisions, be punished by a fine or imprisonment or both. I hereby request payment of living maintenance benefits for the period listed and certify I have contacted each potential employer and the information listed on this job search form is correct to the best of my knowledge. OFFICIAL USE ONLY Injured worker signature Date I have reviewed this information with injured worker Job placement specialist: Date: Field case manager: Date: BWC-2960 (Rev. 12/11/08) RH-10 American LegalNet, Inc. www.FormsWorkflow.com