Self-Restriction to Part-Time Work

Document Number:  WKC-12698-E

Description:  This form should be filed by an injured worker who limited themselves to part-time work. This form is for an injured worker to advise Worker's Compensation whether or not they were self employed or worked for someone else.

Comments:  This form is an electronic Microsoft Word template that can filled out on your computer (if you have Microsoft Word). If you do not have Microsoft Word we are providing a PDF (WKC-12698) which you can print and complete by hand.

Content Contact:  Kathy Froehlich

Document Attachments:

WKC-12698-E (Electronic Version - Word/45 KB)

WKC-12698 (Print Version - pdf/24 KB)

*** If you need to access this form in an alternate format, please send an email to the Content Contact listed above.

*** Should you require the necessary software to view the above attachment, please go to the DWD Viewers Download Page.  Links to each specific vendor's site have been provided for you.  Thank you.