Department of Workforce Development Division of Worker’s Compensation 201 East Washington Avenue P.O. Box 7901 Madison, WI 53707-7901 Telephone: (608) 266-1340 Fax: (608) 257-0394 TTY: (608) 265-3142 Email: dwddwc@dwd.wisconsin.gov NOTICE OF POTENTIAL ELIGIBILITY TO RECEIVE VOCATIONAL REHABILITATION SERVICES Claimant Name Date Address WC Claim No. City, State, Zip Code Insurer Claim No. Employer Name Injury Date Employer Address Insurer Name City, State, Zip Code Insurer Address Insurer/Self- insurer Employer Representative Name City, State, Zip Code Insurer/Self-insured Employer Representative telephone number We have received information indicating your medical healing period has ended. If you have workrelated disability or work restrictions which prevent you from performing the work you were doing when injured, you may be eligible for job placement or retraining services from a vocational counselor. If you have not returned to the job you were doing at the time of injury or a comparable job and would like the assistance of a vocational counselor, you may contact the Division of Vocational Rehabilitation at the Job Center nearest you to schedule an appointment to determine your eligibility. If you need assistance in locating the nearest Job Center or have questions regarding the services provided by DVR, you may contact: DWD - Division of Vocational Rehabilitation – Administrative Office 201 East Washington Avenue P.O. Box 7852 Madison, WI 53707-7852 Main Phone 608-261-0050 Toll Free 800-442-3477 TYY Number 608-264-8749 This notice is sent to you by the insurance carrier or the self-insured employer listed above, pursuant to Wis. Admin. Code §DWD 80.49(7)(a). WKC-17001 (N. 07/2011) American LegalNet, Inc. www.FormsWorkFlow.com