Employment Contact Log {SFN 54198}

EMPLOYMENT CONTACT LOG RETURN TO WORK DIVISION SFN 51498 (02/2017) 1600 E Century Ave, Ste 1 PO Box 5585 Bismarck ND 58506-5585 Telephone 800-777-5033 Toll Free Fax 888-786-8695 TTY (hearing impaired) 800-366-6888 Fraud and Safety Hotline 800-243-3331 www.workforcesafety.com Return this form at least once a week or sooner if it is completed SECTION 1 ­ Injured worker's information Claim number Injured worker's (First name) (Last name) SECTION 2 ­ Contact's information (Complete each box. Put n/a (not applicable) if you don't know the information. Keep a copy for yourself if you need to follow-up with a company.) Number 1 contact MM/DD/YY Ex. 01/01/16 Company name City Telephone number State Contact person Website address Job title or type of work Method of contact In person Telephone Internet Kiosk Comments and outcomes Email Text Mail Results of contact Hiring Application Interview Job offer Number 2 contact MM/DD/YY Ex. 01/01/16 Yes Yes Yes Yes No No No No Company name City Telephone number State Contact person Website address Job title or type of work Method of contact In person Telephone Internet Kiosk Comments and outcomes Email Text Mail Results of contact Hiring Application Interview Job offer Number 3 contact MM/DD/YY Ex. 01/01/16 Yes Yes Yes Yes No No No No Company name City Telephone number State Contact person Website address Job title or type of work Method of contact In person Telephone Internet Kiosk Comments and outcomes Email Text Mail Results of contact Hiring Application Interview Job offer Number 4 contact MM/DD/YY Ex. 01/01/16 Yes Yes Yes Yes No No No No Company name City Telephone number State Contact person Website address Job title or type of work Method of contact In person Telephone Internet Kiosk Comments and outcomes Email Text Mail Results of contact Hiring Application Interview Job offer Yes Yes Yes Yes No No No No Form continued on next page. Submit all pages to WSI. American LegalNet, Inc. www.FormsWorkFlow.com EMPLOYMENT CONTACT LOG (cont'd) Claim number Injured worker's (First name) (Last name) Page 2 of 2 Number 5 contact MM/DD/YY Ex. 01/01/16 Company name City Telephone number State Contact person Website address Job title or type of work Method of contact In person Telephone Internet Kiosk Comments and outcomes Email Text Mail Results of contact Hiring Application Interview Job offer Number 6 contact MM/DD/YY Ex. 01/01/16 Yes Yes Yes Yes No No No No Company name City Telephone number State Contact person Website address Job title or type of work Method of contact In person Telephone Internet Kiosk Comments and outcomes Email Text Mail Results of contact Hiring Application Interview Job offer Number 7 contact MM/DD/YY Ex. 01/01/16 Yes Yes Yes Yes No No No No Company name City Telephone number State Contact person Website address Job title or type of work Results of contact Method of contact Comments and outcomes In person Email Hiring Yes No Telephone Text Application Yes No Internet Mail Interview Yes No Kiosk Job offer Yes No SECTION 3 ­ Fraud warning/signature Fraud warning Any person claiming benefits or compensation from WSI who files a false claim, or makes a false statement, or fails to notify WSI as to the receipt of income or an increase in income from employment, in connection with any claim or application for workers' compensation benefits will forfeit any future benefits and may be guilty of a felony which is punishable by imprisonment, substantial fines, or both. These criminal penalties are applicable to all persons dealing with WSI, including injured workers, employers, medical providers, and attorneys. Signature By signing this form, I acknowledge that I have read and understand the fraud warning. I understand that falsifying this claim or making a false statement regarding this claim may be a felony, punishable by substantial fines and imprisonment. I authorize and agree that statements in this form are true and accurate. Injured worker's signature Date American LegalNet, Inc. www.FormsWorkFlow.com Your Role in the Work Search Process The following information describes your role in the work search process. A good faith work search requires you to complete 5 job contacts per day or a number agreed to by your claims adjuster. Written documentation of these contacts is required and should be documented on the Employment Contact Log form. Contacts may include the following: Visiting a state/federal employment agency (Example: Job Service, Workforce Center) Visiting private employment agency (Example: Spherion, Kelly Services, Manpower) Using the internet to post your resume, look at job postings on an employer's website or elsewhere (Example: Monster.com, Indeed.com, CareerBuilder.com) Attending a job fair Contacting a vocational case manager Reviewing classified ads in local newspapers or other publications in your area that list job openings Following up on applications/resumes submitted Interviewing for a job Asking friends, family, or people in your community about job openings Contacting employers in person or by phone to discuss job openings (cold calls) Contacting employers to submit an application or resume Attending a Workforce Safety & Insurance (WSI) Job Seeking Skills workshop; for upcoming workshops, view our calendar at www.workforcesafety.com Registering for WSI's Preferred Worker Program; for additional information, contact the Return to Work Coordinator at 800-440-3796 ext. 3876 or 701-3283876 Registering with the Division of Vocational Rehabilitation Participating in a mock interview How to have a successful work search Establishing a clear focus and creating structure will help you be successful in your work search. Your first source of information is WSI's Work Search booklet. The booklet contains a lot of information from identifying your skills and creating a resume, to searching for a job and interviewing with employers. Below are some top tips to help you be successful: Have an up-to-date resume Register with your local employment agencies Follow-up immediately on job openings provided by vocational case managers Make sure you are qualified for the jobs for which you apply Apply for jobs within your physical capabilities Practice your interview skills Be prepared, proactive, persistent, and organized Customer Service: 800-777-5033 or 701-328-3800 www.workforcesafety.com American LegalNet, Inc. www.FormsWorkFlow.com