State Agency Referral Form for Field Medical and Vocational Services

The State Agency Referral Form for Field Medical and Vocational Services is another tool available for the Agency to actively participate and be proactive in the early return to work program. This one page form is easy to complete and includes an area for services requested. Examples of these services may include early referral for assistance in obtaining a full duty release to RTW, a release or medical approval for a transitional RTW, accommodations for modified duty, a job analysis. The completed form is faxed directly to the Vocational/Medical Manager George Crickenberger at (804) 649-2397.

If you have any questions, please do not hesitate to contact the Voc/Med Manager, George Crickenberger at (804)775-0710.

• Download Referral Form for Field Medical or Vocational Services (PDF)

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