Workers Comp Information Request
Your Name (first last)
City, State, Zip
Are you any of the following?
Have Workers Compensation Voucher
Injured on Workman's Comp
client of the State Department of Rehabilitation?
Do You Have a workers Compensation Voucher?
Would you like information about how to obtain a Workers Compensation Voucher
Would you like information about customized at home training?
Do You want a rehabilitation counselor to contact you
Which Training Department would be of interest?
How soon would you like to start school?
As soon as possible
Within 30 days
Within 60 days
Your comments, questions, or special issues