Recovery and Return (R&R) Award

Nomination Form

Please complete the form below to submit your nomination for the R&R Award. If you prefer to submit your nomination by mail, click the icon above to download the .pdf and mail the completed form to:

Mississippi Workers’ Compensation Association • P. O. Box 13508 • Jackson, MS 39236-3508

RECOVERY & RETURN AWARD (R&R) NOMINATION FORM

The R&R award is presented annually by the MWCEA to an injured worker in Mississippi that has demonstrated exceptional motivation to obtain physical recovery and return to the productive workforce.

Nominee Information

Please submit current details and contact information for the worker you wish to nominate.

Nominee First Name

Nominee Last Name

Nominee Phone Number

Nominee Email Address

Nominee Street Address

City

State

Zip/Postal Code

Employer Information

Please provide details and contact information for the nominee's employer at the time of the injury.

Employer Name

Total No. of Employees

Employer Phone Number

Employer Email Address

Employer Street Address

City

State

Zip/Postal Code

Nominator Information

Please provide name and contact information for the individual submitting the nomination (if other than employer.)

Nominator First Name

Nominator Last Name

Nominator Phone Number

Nominator Email Address

Nominator Street Address

City

Zip/Postal Code

State

Injury Details

Injury Date

MMI Date

Return-to-Work Date

Employee Returned to Work:

Nature of Injury

Involvement & Motivation

Desire to Return

Communication

Summary & Additional Comments

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Recovery and Return (R&R) Award

Nomination Form

RECOVERY & RETURN AWARD (R&R) NOMINATION FORM

Nominee Information

Employer Information

Nominator Information

Injury Details

Mississippi Workers' Compensation Education Association