Wage and Hour Division (WHD) of the Department of Labor has released Form Wkc 16 which is to be used by all employers to report hours worked, wages paid, and other required information for employees employed on or after December 1, 2016. The updated form replaces the now obsolete Form W-2c. This article provides a brief overview of what employers need to know about the new form. Form Wkc 16 must be filed annually by January 31st for all employees who were employed during the previous year. It must be filed even if an employer did not have any employees working during the previous year. The form can be filed electronically or on paper. Though most of the information on Form Wkc 16 will be familiar to employers who have filed Form W-2 in the past, there are a few changes worth noting. Most notably, there is a new section for reporting hours worked outside of the United States. Employers should also take care to report all income earned by an employee, including tips and bonuses. P
| Question | Answer |
|---|---|
| Form Name | Form Wkc 16 |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | form wkc 16, wkc 16 wisconsin, wkc 16, wkc 16 blank form |
MEDICAL REPORT ON INDUSTRIAL INJURY
Department of Workforce Development Worker’s Compensation Division
201 E. Washington Ave., Rm. C100 P.O. Box 7901
Madison, WI
Telephone: (608)
Fax: (608)
Provision of your Social Security Number (SSN) is voluntary. Failure to provide it may result in an information processing delay. Personal information you provide may be used for secondary purposes [Privacy Law, s. 15.04 (1)(m), Wisconsin Statutes].
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WC Claim Number |
Employee Name |
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PATIENT |
Employee Social Security Number |
Employee Address |
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Injury |
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Employer Name |
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Insurance Company |
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HISTORY |
History as described by patient |
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DIAGNOSIS |
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(Please be as |
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detailed as |
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possible) |
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PERMANENT |
What amputation present? |
Comparative |
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Stump: |
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Ye s |
No |
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hardy or |
tender |
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DISABILITY |
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(Describe permanent |
Has permanent disability resulted? |
Date of Last Exam |
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Has healing period ended? |
Patient discharged? |
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elements of disability, |
Yes |
No |
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Ye s |
No |
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No |
such as limitation of |
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motion, pain, weakness, |
Description of permanent disability (Record finger motion losses on reverse.) |
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etc., and describe effect |
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on working ability.) |
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Was surgery performed as a result of accident? |
Ye s |
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No |
If Yes, state type of surgery: |
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If healing has not ended, what is minimum permanent disability expected? |
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PRIOR |
What previous disability? |
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DISABILITY |
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PROGNOSIS |
Prognosis: |
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Date injured was or will be able to return to a limited type of work: |
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State any limitations: |
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Date injured was or will be able to return to |
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What further treatment should be given? |
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Additional comments, if any:
Date |
City |
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Physician or Chiropractor Signature (in own writing) |
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Phone Number |
Typed or Printed Name |
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- |
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Employee Name
Employee Social Security Number
Instructions for finger injuries
Please use statutory terms in referring to fingers, such as thumbs, index, middle, ring, and little fingers, and distal, middle, and proximal joints. Where there is limitation of motion, list separately the normal range of motion in degrees, the “degrees” loss of flexion, and the “degrees” loss of extension for each joint of each finger. The Worker’s Compensation Division will evaluate the loss of use due to loss of motion of the fingers.
Where there are other elements of disability of the fingers, such as deformity, weakness, pain, or lack of endurance, give your opinion on the percentage loss of use as compared to amputation for such elements of disability and specify the joint at which such loss is estimated.
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Angle |
Normal |
Degrees |
Degrees |
Estimate % loss of use for additional factors at joint |
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Digit |
Joint |
Range of |
Loss |
Loss |
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Ext./Flex |
involved and reason for additional allowance |
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Motion |
Extension |
Flexion |
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Thumb |
Dist |
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Prox |
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Index |
Dist |
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Mid |
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Prox |
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Mid |
Dist |
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Mid |
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Prox |
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Ring |
Dist |
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Mid |
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Prox |
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Little |
Dist |
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Mid |
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Prox |
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CIRCLE HAND INVOLVED: Right Left
Middle Finger
DOMINANT HAND: Right |
Left |
Ring Finger
Little Finger
Distal
Joint
Middle
Joint
Proximal
Joint
Index Finger
Thumb
See DWD 80.32 & 80.33 for guides to evaluation for amputations, restrictions of motion, ankylosis, sensory loss, and surgical results for disability to the hip, knee, ankle, toes, shoulder, elbow, wrist, fingers and back.
If fingertip amputation is present, submit comparative
If amputation is below the distal joint, submit comparative