Form DFS-F3-DWC-27 "Reemployment Services Questionnaire" - Florida

Form DFS-F3-DWC-27 or the "Reemployment Services Questionnaire" is a form issued by the Florida Department of Financial Services.

A PDF of the latest Form DFS-F3-DWC-27 can be downloaded below or found on the Florida Department of Financial Services Forms and Publications website.

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Download Form DFS-F3-DWC-27 "Reemployment Services Questionnaire" - Florida

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D
F
S
EPARTMENT OF
INANCIAL
ERVICES
Division of Workers’ Compensation - Bureau of Employee Assistance
200 E
G
S
, T
, F
32399-4225
AST
AINES
TREET
ALLAHASSEE
LORIDA
REEMPLOYMENT SERVICES QUESTIONNAIRE
Personal Information
Name:
Date of Accident:
Address:
Date of Birth:
Address:
City, State
Zip Code
County
Phone #
Cell Phone #
E-Mail Address:
Preferred Method of Contact:
Email
Phone
Mail
How did you hear about us?
1.
U.S. Citizen:
Yes
No
Resident Alien:
Yes
No
Resident Alien #:
2.
Primary Language spoken:
Secondary Language spoken:
3.
Have you ever been arrested for or charged with a felony or first degree misdemeanor?
Yes
No
Note: The response to this question will not disqualify you from services. This information is required in order to properly
assess your case and put together an appropriate reemployment plan. Approximate arrest dates are acceptable.
If you require additional space, please attach information on a separate sheet.
Date
Charge
State
County
City
Outcome
Employer & Insurer Information
Employer:
Telephone #
Address:
Fax #:
City, State, Zip
E-Mail Address:
Contact person:
WC Carrier:
Telephone #
Address:
Fax #:
City, State, Zip
E-Mail Address:
Adjuster:
Form DFS-F3-DWC-27, Eff. 12/2015
Page 1 of 4
Rule 69L-22.011, F.A.C.
D
F
S
EPARTMENT OF
INANCIAL
ERVICES
Division of Workers’ Compensation - Bureau of Employee Assistance
200 E
G
S
, T
, F
32399-4225
AST
AINES
TREET
ALLAHASSEE
LORIDA
REEMPLOYMENT SERVICES QUESTIONNAIRE
Personal Information
Name:
Date of Accident:
Address:
Date of Birth:
Address:
City, State
Zip Code
County
Phone #
Cell Phone #
E-Mail Address:
Preferred Method of Contact:
Email
Phone
Mail
How did you hear about us?
1.
U.S. Citizen:
Yes
No
Resident Alien:
Yes
No
Resident Alien #:
2.
Primary Language spoken:
Secondary Language spoken:
3.
Have you ever been arrested for or charged with a felony or first degree misdemeanor?
Yes
No
Note: The response to this question will not disqualify you from services. This information is required in order to properly
assess your case and put together an appropriate reemployment plan. Approximate arrest dates are acceptable.
If you require additional space, please attach information on a separate sheet.
Date
Charge
State
County
City
Outcome
Employer & Insurer Information
Employer:
Telephone #
Address:
Fax #:
City, State, Zip
E-Mail Address:
Contact person:
WC Carrier:
Telephone #
Address:
Fax #:
City, State, Zip
E-Mail Address:
Adjuster:
Form DFS-F3-DWC-27, Eff. 12/2015
Page 1 of 4
Rule 69L-22.011, F.A.C.
REEMPLOYMENT SERVICES QUESTIONNAIRE
Claim Status & Medical Information:
1.
Have you settled your claim with the Insurance Carrier?
Yes
No
2.
What part of your body was injured as a result of your accident?
Which side?
Right
Left
Both
If multiple body parts were injured, please identify the other body parts injured:
3.
Do you have pending surgery/additional medical treatment(s)?
Yes
No
If yes, please explain:
4.
Have you been told by your Workers Compensation doctor that you will not be able to return to you previous
position because of your Workers Compensation injury?
Yes
No
5.
Have you been told by your Workers' Compensation doctor that you will have any permanent physical restrictions as
a result of your Workers' Compensation injury?
Yes
No
If yes, what do you understand you physical restrictions to be?
6.
Have you been told by your Workers' Compensation doctor that you have reached maximum medical improvement?
Yes
No
Don't Know
7.
Do you have any other conditions that would affect your ability to return to work?
Yes
No
8.
If yes, explain:
9.
What is your dominant hand?
Right
Left
Both
Form DFS-F3-DWC-27, Eff. 12/2015
Page 2 of 4
Rule 69L-22.011, F.A.C.
REEMPLOYMENT SERVICES QUESTIONNAIRE
Employment & Work History
PLEASE LIST EMPLOYMENT EXPERIENCE FOR THE LAST 15 YEARS.
If you require additional space, please attach information on a separate sheet.
Dates Worked
Name of Employer
Job Title
Job Duties
1.
Have you returned to work?
Yes
No
If no, have you talked with your employer about return to work?
Yes
No
If yes, explain what happened?
2.
Have you looked for work since your injury?
Yes
No
3.
What kinds of jobs were you looking for?
4.
Where have you looked for work?
5.
What jobs have you applied for?
6.
If you have not looked for work please explain why?
7.
Are you an honorably discharged veteran?
Yes
No
Not applicable
Form DFS-F3-DWC-27, Eff. 12/2015
Page 3 of 4
Rule 69L-22.011, F.A.C.
REEMPLOYMENT SERVICES QUESTIONNAIRE
Educational & Transportation Information
1.
PLEASE PROVIDE THE FOLLOWING INFORMATION:
Do you have a high school diploma or GED?
Yes
No
a.
Highest Grade Completed:
b.
Major Area of Study or Certificate Earned:
c.
2.
What type of training have you received from past employers or in the military?
3.
List any other special skills you possess (language, computer, etc):
Please attach copies of all diplomas and/or certificates for any type of training you have received including
any received in the military. Also attach college transcripts for all classes completed.
4.
What transportation is available to you?
Driver’s License:
5.
Yes
No
Class:
Expiration Date:
Suspended within the past 3 years?
Yes
No
If yes, explain
I certify that to the best of my knowledge and belief all of the statements contained herein are true, correct, complete,
and made in good faith.
Injured Employee Signature
Date completed this questionnaire
Form DFS-F3-DWC-27, Eff. 12/2015
Page 4 of 4
Rule 69L-22.011, F.A.C.
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