After 1 year of illness, you and your employee will discuss the action plan. Print the first-year evaluation form and fill it in with your employee. Make sure you both sign the form. Give your employee a copy as they will need it for their return-to-work report. Keep a copy for your own records.

There is no need to send the form to us at this point. If your employee needs to apply for a WIA benefit, this form will be sent to us as part of their return-to-work report.