Returned to Work Information

Congratulations on returning to work!

In order to remove you from our active file please provide us with the following information:

Information about you
First Name
Middle Initial
Last Name
Last four digits of SSN
E-mail Address
Phone number
Current mailing address
Have you been attending school? Yes   No
If yes, does this job relate to your training? Yes   No
Are you currently working with someone in our office? Yes   No
If yes, who?
Information about your employer
Business Name
Type of business
Business Address
City    State    Zip Code
Business phone
Employer or supervisor's name  
Information about your job
Job Title
Date Returned to Work
(mm/dd/yyyy)
Wage
Hours per Week
How often are you paid Weekly   Bi-monthly   Monthly   Other
If this is a temporary job, how long do you expect it to last
Benefits
(check all that apply)		 Medical   Dental   Vacation   Sick leave   Retirement  Vision   Other
How did you learn about this position
Is this the last employer you worked for Yes   No
If yes, is this a new position Yes   No

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