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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
B. Your Education
*Select highest level of education:
*In what Country did you achieve your highest level of education:
  

*Have you received any specialized work training or had an apprenticeship?
If yes, please list:

  

*Have you served in the US military?
C. Your Work Experience
*List all job titles during the past 10 years (such as warehouse worker, cook), most current first.

  

D. Your Knowledge and Use of the English Language
*Select the level of ability to:
*Speak
*Read
*Write
Sign
An individual may sign on behalf of the claimant only if he or she is legally authorized to do so and the claimant is a minor, mentally incompetent or incapacitated.
 
*Prepared By:

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