Employers Efroi Worksheet Page 3

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Return to Work
*Did employee stop work because of injury? Yes____ No____
*If yes on what date? ________________
*Did employee lose more than or is anticipated to lose more than one week of work?
Yes____ No____
*Has employee returned to work? Yes____ No____
*if yes what date __________________________
*If yes in what capacity? Regular Duty____ Limited duty____
If the employee has returned to limited duty what are his average gross earnings per week_______
*If yes did employee return to work with physical restrictions? Yes____ No____
*If yes did Employee return to work with same employer? Yes____ No____
Employees Work info on the date of the injury or illness
Date the employee was hired_________________
Employees’ job title___________________________________
*Occupation Description_______________________________
What types of activities did the employee normally perform at work?
__________________________________________________________________________________
Employees Payroll Information on date of the injury
*Employees gross pay in an average week_________________
*Did the employee receive lodging or tips in addition to pay? Yes____ No____
*Employee job was Regular/Full time, Part time, Seasonal etc.? ____________________
*Which days of the work did the employee usually work?
M____ TU____ W____ TH ____ FRI____ SAT____ SU____
Last day paid____________
*Was the employee paid for a full day on the day of the injury/illness? Yes____ No ____
*Did you continue to pay the employee after the injury? Ex. sick leave, vacation disability regular salary
Yes____ No____

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