Form VDF-1 at a glance
What it is: Form VDF-1 is the Loss of Wage Earning Capacity Vocational Data Form of the Workers' Compensation Board, and the facts on it will be used to determine loss of wage earning capacity.
Who signs: Sign on Signature of Claimant, enter Claimant's Name (please print clearly), and enter the Date.
A filled-in Form VDF-1 example: a warehouse worker lists training and one job
How to fill out Form VDF-1, box by box
A. Your Information
Be sure to enter your name and the date of your injury or illness. Enter your full name. Include first name, middle initial, and last name. Enter your Workers' Compensation Board Case Number, if known. If you do not have or know your Workers' Compensation Board Case Number, please leave this field blank. It is not required to process your claim. Enter your mailing address. Include P.O. Box, if applicable, city or town, state, and Zip code. Enter your Date of Birth. Enter your Social Security Number. This is important to help service your claim faster. Enter Date of Injury.
B. Your Education
Check the box next to the highest level of education you achieved. Check "Yes" if you have completed any specialized training apprenticeship. Check "No" if you have not.
In what Country did you achieve your highest level of education: United States or Other (please specify).
If you answered "Yes", list the type of training and apprenticeship. Provide the date the training or apprenticeship was completed. List any certification or license received and the date it will expire. Check "Yes" if you have served in the U.S. military.
Check "No" if you have not. If you answer "Yes" to the question, identify the branch of the military in which you served. Fill in the dates of service. List any occupational and/or specialized training you received. Identify any degree or certificate you earned.
Please list any additional training. Include the name of the school/program, the date of training and any degree or certificate earned.
C. Your Work Experience
List all job titles during the past 10 years (such as warehouse worker, cook), most current first. Attach additional sheet if necessary.
List your most recent job title (such as warehouse worker, cook). If you had this job with more than one employer, list it just once. List your typical job activities and duties. State how long you held this job.
D. Your Knowledge and Use of the English Language
Indicate your knowledge and use of the English language. Select the level of ability to: Speak Read Write.
Signing the form
This form is signed under penalty of perjury.
Submit signed, original to the Workers' Compensation Board and retain a copy for your records.
Sign on Signature of Claimant, enter Claimant's Name (please print clearly), and enter the Date.
More rules for Form VDF-1
Before completing this form, you may wish to speak to a legal representative. You can also call 1-800-580-6665, and ask to speak with the Board's Advocate for Injured Workers.
Attach extra pages if needed.
Reports may also be filed via facsimile to the Board's statewide fax number, 1-877-533-0337.
Reports should be filed by sending directly to the Workers' Compensation Board with a copy to the insurance carrier.
When attaching additional documents, please include the Board case number (WCB #) on every page.
A potential employer cannot require you to release your workers' compensation records. See Workers' Compensation Law Section 110-a.
Common questions about Form VDF-1
Where do I file it?
Send this form to the Workers' Compensation Board at NYS Workers' Compensation Board Centralized Mailing, PO Box 5205, Binghamton, NY 13902-5205 (Statewide Fax Line: 877-533-0337 on VDF-1 (1-12)).
Sources
[1] Form VDF-1 (1-12), Loss of Wage Earning Capacity Vocational Data Form, New York State Workers' Compensation Board (the Official source link on this page).