Skip main navigation

Outdated or Unsupported Browser Detected
DWD's website uses the latest technology. This makes our site faster and easier to use across all devices. Unfortunatley, your browser is out of date and is not supported. An update is not required, but it is strongly recommended to improve your browsing experience. To update Internet Explorer to Microsoft Edge visit their website.

Medical Treatment Statement

Document Number: WKC-3-E

Description: This form must be completed before a prehearing conference (if one is scheduled) and updated before a formal hearing. The form must be brought to both the conference and hearing.

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-3-E) is also provided for your convenience.

Content Contact: Lynn Weinberger

Document Attachments:

WKC-3-E (Electronic Version - Word/103 KB)

WKC-3-E (Electronic Version - pdf/707 KB)

WKC-3 (Print Version - pdf/124 KB)

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