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  2. Forms Repository

  3. WKC-17001-E, Notice of Potential Eligibility to Receive Vocational Rehabilitation Services

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). We are also providing a PDF (WKC-17001) which you can print and complete by hand.

Content Contact: Lynn Weinberger

Document Attachments:

WKC-17001-E (Electronic Version - Word/57 KB)

WKC-17001 (Print Version - pdf/59 KB)

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

Contact Information

For questions about this form, or if you need this form in an alternate format, please see the Content Contact (listed to the left)

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