Form 100b - Original Notice, Petition, Answer And Order Concerning Vocational Rehabilitation Program Benefit - 2004
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2(TYPE OR PRINT)
14-0009 (9/04)
BEFORE THE IOWA WORKERS' COMPENSATION COMMISSIONER
FORM 100B
Claimant_________________________________________
File Number_____________________________________
ORIGINAL NOTICE, PETITION,
Street____________________________________________
ANSWER AND ORDER
City_________________State______Zip________________
CONCERNING
VS.
VOCATIONAL REHABILITATION
Employer_________________________________________
PROGRAM BENEFIT
Street____________________________________________
(Iowa Code Section 85.70)
City_________________State______Zip_______________
Claimant's
Soc. Sec. No,____________________________________
Insurance Carrier__________________________________
Injury Date_______________________________________
Street____________________________________________
Body Part(s) Injured________________________________
City_________________State______Zip________________
ORIGINAL NOTICE
To the Above-Named Employer:
You are notified
that an action has been commenced before the Iowa Workers' Compensation Commissioner seeking relief as set forth in the petition
below. You are required to file and serve an answer to the petition (SEE REVERSE SIDE OF FORM) within 20 days following your receipt of this
document or to otherwise move or respond as provided by Division of Workers' Compensation rules. Failure to comply may result in the
imposition of sanctions under rule 876 IAC 4.36 and/or entry of a default and an award for the relief requested. NOTE: You should promptly
advise your workers’ compensation insurance carrier and attorney that you have received this notice.
PETITION
(To Be Completed By Claimant and Vocational Rehabilitation Counselor)
Claimant requests
a vocational rehabilitation program benefit in accordance with Iowa Code section 85.70, as follows:
Training
Facility___________________________________________________________________________________________________________________
NAME
CITY
STATE
Type of
Training__________________________________________________________________________________________________________________
Training will be for ____________weeks, commencing________________________________, ________.
This training is part of a vocational rehabilitation program recognized by the State Board for Vocational Education. Completion of the
program will likely accomplish rehabilitation.
Signature of
Rehabilitation Counselor_________________________________________Date Signed_______________________Phone (
) ________________
IN SUPPORT of this request claimant states:
1.
Claimant sustained injury arising out of and in the course of employment with the employer on (Date)___________________________________
2.
The injury occurred at (City) ______________________________________ (County) __________________ (State)______________________
3.
Claimant has not returned to gainful employment and cannot do so because of permanent disability resulting from the injury as shown by
the attached medical report.
4.
Evidentiary hearing under Iowa Code section 17A.12 is waived.
I, (Claimant's Signature) __________________________________________,
Date Signed____________________________________
certify, under penalty of perjury and pursuant to the laws of the
Claimant's Phone No.
State of Iowa, that the preceding petition is true and correct.
(Include Area Code)_________________________________________
(If Represented by Attorney)
Attorney__________________________________________________
Street____________________________________________________
City__________________________State___________Zip__________
________________________________________
Phone (Include Area Code)___________________________________
Signature of Attorney
THE INFORMATION PROVIDED WILL BE OPEN FOR PUBLIC INSPECTION UNDER IOWA CODE § 22.11
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