Form 206 11/2004 STATE OF UTAH – LABOR COMMISSION Division of Industrial Accidents P. O. Box 146610, Salt Lake City, UT 84114-6610 INJURED WORKER STATUS REPORT Directions: This report must be submitted when an injured workers’ temporary total disability compensation period exceeds 90 days or when it appears that an injured worker is or will be a disabled injured worker, whichever occurs first. (Section 34A-8-106) GENERAL INFORMATION Name Claim Number Address Date of Injury Phone Number Social Security Number Employer (Name, Address, Phone Number) Occupation of Injured Worker Pre-injury Weekly Wage $ ___________________ Insurance Carrier – Adjustor’s Name & Phone Number Private Rehabilitation Provider (Name, Phone Number) STATUS – EXPECTATIONS OF RTW: Employer: _________________ ____________________________________________________________  A. Reemployment Assistance IS Necessary Check “A” if reemployment assistance is needed; also, circle recommended services. * * * * * * * * * * Counseling Vocational Evaluation Job Placement Job Seeking Skills Reemployment Plan On the Job Training Transferable Skills Analysis Jobsite Modification Coordinate Reemployment Retraining Referral for vocational rehabilitation services are made to a qualified rehabilitation provider:  B. Unable to Determine Need or Proceed with Assistance Check “B” if any of the following are true; also, circle appropriate response below. * Not yet medically stable (no MMI date) and physically capacity yet to be determined. * Worker is currently involved in light duty “trial work activities. * Claim liability is under review. * Worker has marketable skills, 60 day monitoring begins: DATE ____/_____/____ * Worker has returned to work, 60 day monitoring begins: DATE ____/____/____ * Briefly describe the Postponement: Agency __________________ Counselor ________________ Referral Date _____________ cc: Injured Worker Employee: ________________________________ __________________________________________ Estimated Date of Resubmission: _____________________________  C. Employment Assistance is NOT Necessary Check “C” if reemployment assistance is not necessary. (Specify reasons below.) * Worker returned to work (RTW) and 60 days monitoring complete: Date RTW ____/____/____ Same Employer _____________ New Employer ______________ Self Employed ______________ Same Job ___________________ New Job ___________________ Modified Job _______________ RTW wage $______ Wkly. wage * Worker RTW as a result of vocational rehabilitation support services. Type of service(s) ___________ __________________________ Cost of Service(s) ___________ __________________________ * Disability too severe to return to work. * Other (specify) ________________ _____________________________ American LegalNet, Inc. www.USCourtForms.com