Preferred Worker Program Substantial Modification Determination
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Preferred Worker Program Substantial Modification Determination Form. This is a Oregon form and can be use in Preferred Worker Program Workers Comp.
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Tags: Preferred Worker Program Substantial Modification Determination, 3297, Oregon Workers Comp, Preferred Worker Program
COURT
COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
......... ..
:
Index No.
:
Calendar
Preferred Worker Program No.
:
Substantial Modification Determination
JUDICIAL SUBPOENA
Plaintiff(s)
-against-
:
Worker name:
Date:
:
WCD file no:
Job title and brief job description:
:
Defendant(s)
:
......................................................
THE PEOPLE OF THE STATE OF NEW YORK
Worker injury:
TO
Permanent limitations:
GREETINGS:
WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before
Worksite modification:
,
the Honorable
at the
Court
located at
County of
in room
, on the
day of
, 20
, at
o'clock in the
noon, and at any recessed
or adjourned date, to testify and give evidence as a witness in this action on the part of the
Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to
the party on whose behalf this subpoena“substantialfor a maximum penalty of $50OARall damages sustained as a
Decision: Is the worksite modification a was issued modification” according to and 436-110-0380(3)?
result of your failure to comply.
Yes
No
Comments: Witness, Honorable
Court in
County,
, one of the Justices of the
day of
, 20
(Attorney must sign above and type name below)
Date letter sent to the worker, if applicable:
Attorney(s) for
(Letter states date on which substantial modification was determined and the date by which the preferred worker identification
card and wage subsidy agreement must be completed and sent to WCD, if these are to be requested for the current job.)
Office and P.O. Address
X
Re-employment consultant
Workers’ Compensation Division
Department of Consumer and Business Services
440-3297 (11/01/DCBS/WCD/WEB)
Telephone No.:
Facsimile No.:
E-Mail Address:
Mobile Tel. No.:
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