The Department of Workforce Development's Worker’s Compensation Division in Wisconsin utilizes the Wkc 6743 form, a pivotal document designed for the reporting of vocational expertise in cases of permanent disability resulting from non-scheduled injuries. Unlike scheduled injuries, which pertain to specific body parts such as eyes, ears, and limbs and are addressed under sections 102.52 to 102.55 of the statutes, non-scheduled injuries encompass a broader range of conditions that may affect an individual's employability. The form seeks detailed information about the employee, including but not limited to, their social security number, date of the accident or first illness, highest level of formal education, previous employment history, and the nature of the injury, alongside the type of surgery if applicable. It is meticulously structured to capture the essence of the employee's preexisting conditions, special skills, and the resulting physical or mental limitations as appraised by medical or chiropractic opinion. Furthermore, it assesses the weekly wage at the time of injury compared to the present wage for comparable work with the same employer, types of now available employment considering the employee's age, education, work history, and limitations, as well as the rate of pay for such employment within the general locality. The form crucially facilitates the calculation of loss of earning capacity, guiding through a percentage estimate that reflects the extent of partial or total permanent disability, incorporating considerations for retraining or vocational rehabilitation. Professionals tasked with completing the form are urged to provide their qualifications, underscoring the importance of a credible and comprehensive vocational expert report. The detailed provisions encapsulated within the form underscore the complexities of addressing permanent disabilities in the workforce, reflecting a meticulous approach towards ensuring fair compensation and support for affected employees.
| Question | Answer |
|---|---|
| Form Name | Form Wkc 6743 |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | wkc_6743 wiscinsin workers compensation wkc6743 form |
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Department of Workforce Development |
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Worker’s Compensation Division |
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201 E. Washington Ave., Rm. C100 |
Vocational Expert Report |
P.O. Box 7901 |
Madison, WI |
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s. 102.17(1)(d) |
Telephone: (608) |
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Fax: (608) |
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http://dwd.wisconsin.gov/wc |
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Note: This report is for use with permanent disability caused by
injuries only. It is not to be used for scheduled injuries as described in sections 102.52 to 102.55 of the statutes which include injuries to eyes, ears, and limbs.
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].
WC Claim Number |
Employee Name |
Employee Birth Date |
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Employee Social Security Number
Employer Name
Date of Accident or First Illness
Highest Level of Formal Education Completed
Vocational Education or Training Completed
Previous Employment
Employer Name
Mailing Address (number, street, city, state, zip code)
Job Duties
Date Hired
Date Job Terminated
Employer Name
Mailing Address (number, street, city, state, zip code
Job Duties
Date Hired
Date Job Terminated
List special skills affecting employee’s employability:
List employee’s preexisting physical or mental limitations:
Nature of Injury |
If surgery, give type |
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Resulting physical or mental limitations based on medical or chiropractic opinion:
Weekly wage at time of injury
$
Present wage for comparable work with same employer
$
Types of employment now available given age, education, work history, and physical and mental limitations of employee:
Continue on reverse side |
Pay rates for types of employment listed in previous question for the general locality
If presently employed, identify the following:
Employer:
Pay Rate: $
Nature of Work Performed:
Date Started:
Percent of loss of earning capacity to a reasonable probability due to the injury described under Nature of Injury. Give a single number percentage or a percentage range, and use the following guidelines to assist with the calculation:
________________________%
A person may be classified as permanently partially disabled when by reason of his or her physical or mental condition he or she has limitations in the performance of his or her work activities. The percentage of such partial disability shall be to the degree that such disability relates to permanent total disability. The expert’s opinion should include evaluation of how the disability affects this individual, having in mind his or her education, work history, training, and whether he or she can be retrained or vocationally rehabilitated.
A person may be classified as permanently totally disabled when by reason of his or her physical or mental condition he or she can perform no services other than those which are so limited in quality, dependability, or quantity that a reasonably stable market for them does not exist.
Factors other than those identified above that were considered in analysis (if applicable):
Qualification of Expert (may attach curriculum vitae):
Education: list degree(s), field of study(ies), and date(s)
Work History:
Expert Signature
Expert Name (print or type)