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* 1. Respondent Name:

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* 2. Email:

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* 3. Title

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* 4. County:

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* 5. Date of incident (enter as MM/DD/YYYY):

Date

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* 6. Please describe the incident/problem encountered. Include person/group contacting your department, a detailed description of the problem encountered (i.e. no federal ID number), and what assistance/guidance the LHD provided:

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* 7. Length of time it took to resolve incident:

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* 8. Did the individual/organization contact the helpline at Worker's Compensation?

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* 9. If yes, and if they shared this information, what information/assistance did they receive from the helpline?

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* 10. Was your LHD able to issue the permit within the time frame needed by the organization (if the Worker's Comp paperwork was the only issue needing resolution)?

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* 11. Additional Comments:

T