The Subsequent Injury Fund is intended as an incentive to employers to hire persons having a disability which is a barrier to
employment. This program may NOT be used as a means of discrimination against you. Various laws have been enacted to prevent
discrimination on the basis of a person’s disability.
The Workers’ Compensation Act provides that an injured worker who has been medically released and is capable of returning
to work within two (2) years of injury must be given hiring preference over other applicants for a comparable position that becomes
vacant if the position is consistent with the workers’ physical condition and vocational abilities; and
The Human Rights Act prohibits discrimination against handicapped individuals if they are otherwise qualified to perform
duties of the job with reasonable accommodations by the employer.
The Americans Disabilities Act prohibits employers of 15 or more employees from discriminating against qualified workers or
job applicants on the basis of their disability.
If you feel an employer is discriminating against you or using the Subsequent Injury Fund to discriminate against you, call the
Human Rights Commission at 1-800-542-0807.
RESPONSIBILITIES AND CONSENT
I understand and agree I am applying for certification as a person having a disability. I believe I have a medically certifiable
permanent impairment, which is a substantial obstacle to obtaining employment. SIGNING THIS APPLICATION FORM FOR
CERTIFICATION IS MY AUTHORIZATION FOR RELEASE OF HEALTH CARE INFORMATION, MEDICAL
RECORDS, WORKERS’ COMPENSATION, REHABILITATION RECORDS AND RECORDDS OF THE SOCIAL
SECURITY ADMINISTRATION TO THE SUBSEQUENT INJURY FUND, EMPLOYMENT RELATIONS DIVISION.
SIGNATURE OF APPLICANT
Name and Address of Referring Agent
ERD – 985 (REV. 07/05/2000)