Are you aware of any recent pain or disability in the

area of the worker’s reported injury? NO
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Did the worker miss any time from work beyond the
date of injury? YES
Last Day Worked
Last day worked: 2026/01/22
Did the worker continue to work past the day of
injury? YES
Number of hours worked on the last day worked: 10.00
Number of hours paid by employer on the last day
worked: 10.00
Number of hours scheduled to work on the last day
worked: 10.00
Amount paid for the last day worked: $ 473.40

Employment Details

Is the worker's employment (permanent or

temporary)? Permanent
At the time of the injury, was the worker full time or

part time? Full Time
Has the worker been employed by the firm for less

than 12 months NO
Earnings

Is employer continuing to pay worker full salary? YES

Please explain:

payee 2

Worker's base salary for this employment at the time

of injury: $ 47.34 per: Hour(s)
Worker's gross earnings for the past 3 month(s) prior to date of injury were $ 28,734.58

Amount of earnings for the past 12 months prior to
date of injury: $ 110,801.16

-~ Additional Pay

Does worker receive other amounts of compensation
in addition to base salary? YES

What other compensation does the worker receive?
Overtime

Shift Information

Does the worker have a fixed shift? YES
Fixed Shift

Show normal work week by entering paid hours:
Mon Tue Wed Thu Fri Sat Sun
10.00 10.00 10.00 10.00

Does the worker work variable shifts (no steady

employment pattern)? YES
Are there days of the week that the worker is never
scheduled to work? NO

Apprenticeship

Is the worker in an apprenticeship program? NO

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Additional Information

Additional information:

payee 2

Return to Work

Has the worker returned to work? NO

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