Form Hrd(Tdi)-1 - Claim For Temporary Disability Benefits Page 3
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3PART C – DEPARTMENT’S STATEMENT
IMPORTANT: Part C must be completed in its entirety.
1.
Claimant worked:
2.
Date hired:
3.
Date last worked prior to disability:
Full-time;
Part-time
(Mo/Day/Yr)
/
/
(Mo/Day/Yr)
/
/
4.
If returned to work, give date:
5.
Circle days normally worked:
Su
M
T
W
Th
F
Sa
(Mo/Day/Yr)
/
/
If on rotation, give number of days worked per week:
days/week.
6.
Do you think disability was caused by claimant’s job?
7.
Was an Employer’s Report of Industrial Injury WC-1 filed?
Yes,
No,
Unknown
Yes,
No
8.
Has or will this employee receive wages, salary, sick leave, or vacation pay for all or any part of the period of disability covered by this
claim?
No,
Yes
from
through
.
Amount:
(Month/Day/Year)
(Month/Day/Year)
9.
Enter the following for the past 52 weeks prior to date disability began:
Calendar
Number of
No. of Hours
Total Wages
Quarter Ending
Weeks Worked
Worked per Wk.
Earned
10. In reporting wage information below, use gross wages which include wages and all other remuneration such as cash value of meals,
lodging, etc. (Answer either A or B.) If claimant was paid:
A.
On a salary basis and received no other form of remuneration, enter monthly salary amount
for month disability began: $
.
B.
On an hourly or salary basis and received other forms of remuneration give rate per hour: $
.
Enter weekly earnings for the past 8 weeks prior to date disability began, including last date worked.
Week
Week Ending
No. Days
Gross Amount
No.
Worked
Month
Day
Year
1
Complete for A and B
2
Weekly Benefit Amount $
3
No. of Weeks Eligible
4
5
6
7
8
TOTAL
XXXX
XXXX
XXXX
Meets requirements; approved.
Disapproved; Reason:
Signature of Department Head/Designee
Title
Date
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