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 be filled out on your computer (if you have Microsoft Word).  An electronic PDF (WKC-9380-E) is also provided for your convenience.

Content Contact: Lynn Weinberger

Document Attachments:

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

WKC-12698-E (Electronic Version - pdf/24 KB)

Note: If you need this form in an alternate format, please send a message to the Content Contact listed above.