Home > Forms Repository > Self-Restriction to Part-Time Work, WKC-12698-E

Self-Restriction to Part-Time Work

Document Number:  WKC-12698-E

Description:  his 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 be 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:  Don Martin

Document Attachments:

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

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

***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.

---

Wisconsin.gov | Site Map | Search | Accessibility | Legal | Feedback | DWD Home