Loss of Wage Earning Capacity Vocational Data Form

VDF-1

State of New York - Workers' Compensation Board

THIS FORM MAY ONLY BE SUBMITTED ELECTRONICALLY. DO NOT MAIL.

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. Please answer all questions completely.

Required items are indicated by an *

A. Your Information

WCB Case Number (if known):

* First Name: * Last Name: MI:

* Mailing Address:

Address Line 2:

* City: State: Zip Code: Country:

* Date of Birth:

Social Security Number:

* Date of Injury/Disablement:

B. Your Education

*Select highest level of education:

Less than High School High School Diploma or GED Some College College Graduate

*In what Country did you achieve your highest level of education:

United States Other Country:

*Have you received any specialized work training or had an apprenticeship?

Yes No

If yes, please list:

Training:

Date Completed:

Certification/License received:

Expiration date of Certification/License:

*Have you served in the US military?

Yes No

Branch:

Dates:

Specialized training while in the US military:

List any additional training. Include the name of the school/program, the date of training and any degree or certificate earned.

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C. Your Work Experience

*List all job titles during the past 10 years (such as warehouse worker, cook), most current first.

Job Title:

Job Duties:

Length of Time in this Job (in years):

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