Form Wkc-10369 - Private Vocational Rehabilitation Services Quarterly Report
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1Department of Workforce Development
Worker’s Compensation Division
201 E. Washington Ave., Rm. C100
PRIVATE VOCATIONAL REHABILITATION
P.O. Box 7901
SERVICES QUARTERLY REPORT
Madison, WI 53707-7901
Imaging Server Fax: (608) 260-2503
Telephone: (608) 266-1340
Fax: (608) 267-0394
Provision of your Social Security Number (SSN) is voluntary. Failure to provide it may result in an
e-mail: DWDDWC@dwd.wisconsin.gov
information processing delay.
Personal information you provide may be used for secondary purposes [Privacy Law, s. 15.04(1)(m), Wisconsin Statutes].
The Quarterly Report should be completed for each WC claimant receiving return to work services from the certified
specialist and submitted to the WC Rehabilitation Unit by the 5th day of the months April, July, October and January of
each year.
Claimant Name ___________________________________ Social Security Number_____________________________
Provider Name _______________________________________ Provider Number______________________________
Provider Address __________________________________________________________________________________
CURRENT STATUS
Please check the appropriate boxes and fill in the blanks as requested.
Denied private rehabilitation services by the carrier because___________________________________________
________________________________________________________________________________________________
Conducting Job Search
In Retraining for ________ weeks in ______________________________________________________ program
Employed (check the correct response)
1. Same employer:
Same job
Different job
2. Different employer
Post injury wage ____________________ per week
Post injury occupation_________________________________________________________________________
No longer eligible, case fully compromised
Claimant terminated relationship because _________________________________________________________
Specialist terminated relationship because_________________________________________________________
CLOSURE INFORMATION
Please fill in the blanks and check the appropriate box as requested.
_____________ Number of days in Job Search before placement
_____________ Costs of Job Search phase, and ________ Hourly rate for service
_____________ Number of weeks in Retraining
_____________ Costs of services during or following retraining
Did your costs exceed the cap as determined per DWD 80.49(7)(e)?
Yes
No If yes, please describe what
arrangements were made among all concerned parties to cover your fees?
Signature: ___________________________________________________ Date Signed: ________________________
WKC-10369 (R. 12/2009)
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