Reemployment And Annual Case Status Review Form

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FLORIDA DEPARTMENT OF LABOR AND EMPLOYMENT SECURITY
FOR CARRIER'S DATE STAMP
SENT TO DIVISION
DIVISION OF WORKERS' COMPENSATION
BUREAU OF REHABILITATION & MEDICAL SERVICES
2728 Centerview Drive, 100 Forrest Building
Tallahassee, Florida 32399-0664
REEMPLOYMENT AND ANNUAL CASE STATUS REVIEW FORM
1.
Reemployment Case Status Review
2.
Annual Case Status Review
3. Employee Name
4. Social Security Number
5. Date of Accident (MM/DD/YY)
6. Education
7. Carrier Code
8. Carrier or SC/TPA Name, Address &
Telephone Number
School 1 2 3 4 5 6 7 8 9 10 11 12
9. Carrier FEIN
College 12 13 14 15 16 17 VO-TECH
10. Name of Person Completing Form
11. SC/TPA Code
12. Date Form Completed (MM/DD/YY)
13. SC/TPA FEIN
PART I Complete if injured employee receives indemnity benefits and has not returned to work 60 days after the date of injury.
Check appropriate box:
14.
Yes
No
Employer made commitment to rehire employee.
15.
Yes
No
Employee has been conducting job search.
16.
Yes
No
Medical care coordination provided.
17.
In-house provider
18.
Yes
No
Reemployment assessment provided.
19.
Yes
No
Voluntary reemployment services provided.
20.
Yes
No
Employee referred to the Division for a screening.
21.
Yes
No
Trial period of reemployment.
PART II Complete if injured employee has attained MMI or is participating in Trial Reemployment. Please attach DWC-9a.
22. Date of hire
23. Current earnings (if any)
Job History:
Current Job, if any:
PART III Completed on all LES forms DWC-22.
If Reemployment Status Review, explain in detail the likelihood of reemployment (leave blank if Annual Case Status Review):
(Attach additional pages if necessary)
If Annual Case Status Review, explain to what extent the employee's permanent impairment rating contributes to any unemployment or
underemployment (leave blank if Reemployment Status Review):
Maintain the original of this form in your file and send a copy to the Division of Workers' Compensation.
LES Form DWC-22 (08/30/95)

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