C 258 Form – Claimant's Record of Job Search Efforts

C 258 Form PDF Details

The C 258 form, officially titled the Claimant's Record of Job Search Efforts/Contacts, is issued by the New York State Workers' Compensation Board (WCB). Claimants who receive workers' compensation benefits and are required to demonstrate active job searching must complete this form to document every employer contact made during each reporting period. The WCB uses the form to verify that claimants are genuinely seeking employment while receiving temporary disability benefits.

Each entry on the form requires the following information:

• Date of contact: The exact date you contacted the employer, agency, or labor union.
• Employer name and address: The full legal name and complete mailing address of the employer or agency.
• Person contacted: The name of the individual you spoke with or directed your application to.
• Position applied for: The specific job title applied for. Do not use vague entries such as "any available position."
• Contact method: Enter T for Telephone, P for In Person, or R for other methods including online applications and written correspondence.
• Application taken and result: Record whether an application was submitted and the outcome of the contact, such as no opening, application accepted, or interview scheduled.

Supplementary materials, including resume copies, application confirmation emails, printed cover letters, and inquiry letters, should be attached to the completed form. These documents can be critical evidence if the form is reviewed at a WCB hearing. Failure to attach supporting materials may weaken your job search record.

The WCB may review the C 258 at scheduled hearings to confirm that the claimant is actively seeking work. Incomplete or inaccurate entries can result in delays, reduction, or suspension of compensation benefits. Retain a personal copy of every submitted form for your own records. Claimants enrolled in an approved vocational retraining program through the WCB may have different or reduced documentation requirements. Confirm your specific obligations with your WCB case manager or workers' compensation attorney before omitting any contacts.

For related documents, see the job search logs form for tracking contacts over multiple weeks, or the Workers' Compensation C-4 form submitted by treating physicians to the WCB to report on medical status.