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

r— 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
r— Additional Information

Additional information:

payee 2

Return to Work
Has the worker returned to work? NO
Do you have any modified or transitional duties
available? YES

Please explain/describe modified or transitional duties:
Company has a recovery at work program.

Have the modified or transitional duties been
offered to the worker? NO

r— Objection Section

Do you have any objections regarding the

acceptance of this claim? YES

Reason for objection:

There are apparently 4 workstations in the room and employee could have easily moved. Course is 12 days long in classroom and employee did not raise
safety issue until day 8. There were 2 classes prior to this class and no issues reported.