Notice of Potential Eligibility to Receive Vocational Rehabilitation Services

Document Number:  WKC-17001-E

Description:  This form is sent by an insurance carrier to the injured worker notifying them of potential eligibility for services from DVR.

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-17001) which you can print and complete by hand.

Content Contact:  Kathy Froehlich

Document Attachments:

WKC-17001-E (Electronic Version - Word/56 KB)

WKC-17001 (Print Version - pdf/19 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.