WC-VR-01 Revised 04/03/2018
State of New Hampshire
Department of Labor
REQUEST FOR JOB MODIFICATION PLAN APPROVAL
EMPLOYEE NAME:___________________________________SSN:________________DOI:___________
EMPLOYER NAME:______________________FEIN:________________TELEPHONE:________________
EMPLOYER ADDRESS:__________________________________________________________________
DESCRIPTION OF EMPLOYEE’S IMPAIRMENT WITH ATTACHED MEDICAL RELEASE TO RETURN TO
WORK OR WITH ANTICIPATED RELEASE DATE:
DESCRIBE THE SPECIFIC JOB MODIFICATIONS:
PROPOSED COSTS FOR MATERIALS, EQUIPMENT, AND LABOR WITH ESTIMATES:
DATE SUBMITTED:________________________
SUBMITTED BY:__________________________
TITLE___________________________________
Send check to: _____APPROVED
_____NOT APPROVED
Attention _________________________________
_________________________________________
_________________________________________ _______________________________________
_________________________________________ DEPARTMENT REPRESENTATIVE DATE
Vendor No: _______________________________
Email Address: ____________________________
Hugh J. Gallen
State Office Park
Spaulding Building
95 Pleasant Street
Concord, NH 03301
603/271-3176
TDD Access: Relay NH
1-800-735-2964
FAX: 603/271-6149
http://www.nh.gov/labor
Ken Merrifield
Commissioner
Rudolph W. Ogden, III
Deputy Commissioner
