The injured worker and treating physician will be instructed to complete this form while the injured worker is on a light duty status to report earnings and calculate compensation owed. This form must be completed in its entirety.  Failure to do so may cause a delay in processing.

IMPORTANT:  Any person who knowingly makes a false statement or representation to obtain any compensation, benefit or payment is guilty of a class 6 felony and is subject to up to one and one-half years in prison, a fifty thousand dollar fine and forfeiture of benefits.