Record Of Employment Contacts
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1Record of Employment Contacts
Employee Name _____________________________________ Telephone No. _____________________
Address ______________________________________________________________________________
City ____________________________ State ____________________________ Zip ________________
Employer _____________________________________________________________________________
Insurance Carrier _______________________________________________________________________
Date of Injury _________________________________________________________________________
This is a record of the employers contacted by the above-named employee for the week of:
____________________________________________
( month / day / year
—
month / day / year )
Date
Employer Name
Phone
Type
Person
Result
Referral
of Contact
and Address
Number
of Job
Contacted
of Contact
Source
You may copy this form for future use in your job search or you may submit sheets in your own handwriting.
A copy of your record of job search efforts should be forwarded to the workers’ compensation insurance carrier or self-insured
employer for its review. Be sure to include all the necessary information and make a copy for your own records. Don’t forget to
indicate your efforts to obtain employment through the Connecticut Job Service and/or other referral sources.
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Parent category: Business