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OhioBWC - Worker - Form:  (C-141) - Introduction

Wage Loss Statement for Job Search (C-141)
Introduction
Injured workers, who've already applied for or are receiving wage loss, use this form to document the employers they contact and the results of those contacts during weekly job searches. BWC bases eligibility for non-working wage loss compensation on evidence of their continued job search efforts.

Required information
  • Dates corresponding to the week of the job search
  • Earnings received from working during the period (if applicable).
  • Specific information for each employer contacted during the job search including: employer name, address, and telephone number; description of job applied for; contact person; date of contact; method of contact; and result of contact.


If you have all the required information on hand, simply click the start button to begin.

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