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OMB APPROVAL
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- -------- OMB Number: 3235-0104
FORM 3 Expires: September 30, 1998
- -------- Estimated average burden
hours per response .... 0.5
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UNITED STATES SECURITIES AND EXCHANGE COMMISSION
WASHINGTON, DC 20549
INITIAL STATEMENT OF BENEFICIAL OWNERSHIP OF SECURITIES
Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934,
Section 17(a)
of the Public Utility Holding Company Act of 1935 or Section 30(f)
of the Investment Company Act of 1940
(Print or Type Response)
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<S> <C> <C> <C>
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1. Name and Address of Reporting Person* 2. Date of Event Requiring 4. Issuer Name and Ticker or 6. If Amendment, Date
House E. Michael Statement Trading Symbol of Original
- ---------------------------------------- (Month/Day/Year) Work Recovery, Inc. WRKE (Month/Day/Year)
(Last) (First) (Middle) 11/4/97 ------------------------------------
75 Milford Road ---------------------------- 5. Relationship of Reporting 7. If Individual
- ---------------------------------------- 3. IRS or Social Security Person(s) to Issuer or Joint/Group
(Street) Number of Reporting (Check all applicable) Filing (Check
Person (Voluntary) --- Director X 10% Owner Applicable Line)
Hudson OH 44236 --- Officer --- Other (specify X Form filed by One
- -------------------------------------- ---------------------------- (give --- below) --- Reporting Person
(City) (State) (Zip) title below)
Form filed by More
--- than One Reporting
Person
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TABLE 1 -- NON-DERIVATIVE SECURITIES BENEFICIALLY OWNED
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1. Title of Security 2. Amount of Securities 3. Ownership Form: 4. Nature of Indirect
(Instr. 4) Beneficially Owned Direct (D) or Beneficial
(Instr. 4) Indirect (I) Ownership (Instr. 5)
(Instr. 5)
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Common Stock, $.01 par value 3,680,707.5 I By Functional Capacity
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Evaluation Technologies,
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Inc.
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Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. (Over)
* If the form is filed by more than one reporting person see Instructions 5(b)(?)
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FORM 3 (CONTINUED) TABLE II -- DERIVATIVE SECURITIES BENEFICIALLY OWNED
(E.G., PUTS, CALLS, WARRANTS, OPTIONS, CONVERTIBLE SECURITIES)
<S> <C> <C> <C> <C> <C>
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1. Title of Derivative Security 2. Date 3. Title and Amount of 4. Conver- 5. Owner- 6. Nature of Indirect
(Instr. 4) Exercisable and Securities Underlying sion or ship Beneficial Ownership
Expiration Date Derivative Security Exercise Form of (Instr. 5)
(Month/Day/ (Instr. 4) Price of Deriv-
Year) Deri- ative
vative Security:
Security Direct
--------------------------------------------------- (D) or
Date Expira- Amount of Indirect (I)
Exercis- tion Title Number (Instr. 5)
able Date of Shares
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Option 11/4/97 (1) Common Stock, $.01 par value (2) (3) I (4)
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Explanation of Responses:
(1) No fixed date of expiration -- termination upon certain defined events
(2) 3,680,707.5
(3) See Schedule 13D filed December 19,1997
(4) By Fuctional Capacity Evaluation Technologies, Inc.
/s/ E. Michael House 12/19/97
**Intentional misstatements or omissions of facts constitute Federal Criminal ------------------------------- -------------
Violations. See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a). **Signature of Reporting Person Date
Note. File three copies of this Form, one of which must be manually signed. Page 2
If space provided is insufficient, See Instruction 6 for procedure. SEC 1473 (7/96)
Potential persons who are to respond to the collection of information contained in this form
are not required to respond unless the form displays a currently valid OMB Number.
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