This form is to be used as referral for Special Fund’s Vocational Rehabilitation program. The claim may be unscheduled with carrier involvement or scheduled claim where the injured worker is medically unable to return to work at time of discharge. Carrier, self-insured, and/or TPA representative to complete the information requested on the form and submit pertinent medical data, such as operative reports and medical supporting discharge from active care. A complete file is not required.
