Minnesota > Workers Comp
Retraining Plan EP04 - Minnesota
| Retraining Plan Form. This is a Minnesota form and can be used in Workers Comp . |
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Mail completed copy to: Retraining Plan Department of Labor and Industry Please PRINT OR TYPE your responses 443 Lafayette Road North All dates must be entered in MM/DD/YYYY EP 0 4 St. Paul, MN 55155 (651) 284-5030 or 1-800-342-5354 (DIAL-DLI) DO NOT USE THIS SPACE Private or confidential data which you supply on this form will be used to process your workers compensation file. You may refuse to supply the data, but your request may be delayed, or under Minn. Stat. Sec. 176.275, the Department may refuse to accept any formal document that lacks identifying information. This data may be supplied to employers and insurers for the claimed date of injury, the Department of Revenue, the Department of Health and the Workers Compensation Reinsurance Association. It may also be used in workers compensation hearings and for state investigations and statistics. SOCIAL SECURITY NUMBER DATE OF INJURY EMPLOYEE NAME EMPLOYER NAME INSURER/SELF-INSURER/TPA INSURER CLAIM NUMBER CLAIM REPRESENTATIVE PHONE NUMBER Pre-Injury Job Title Pre-injury Econom ic Status Current Compensation Rate Occupational Goal(s) Anticipated Economic Status (from Labor Market Survey) Certificate/Degree Program Title Pr ogram Length ( Weeks) Program Start Date Program Completion Date School Name City, State ITEMIZED COSTS: * Explain (for example, tutoring, board and lodging, etc.) Tuition/Lab/Activity Fees Books/Tools Special/Unique Costs* Custodial Day Care Mileage/Parking Total Retraining Costs (Excluding Wage Benefits) REQUIRED ATTACHMENTS: Pursuant to Minn. Rule 5220.0750, subp. 2(H), the following items MUST BE ATTACHED. a. Course syllabus/class titles. b. Physical requirements of the job for which the employee is being trained (On-Site Job Analysis is preferred). c. Medical information that the training and the occupational goals are within the employees restrictions. d. Test results which support course choice. e. Recent labor market survey. MN EP04 (4/03) -over- cc: Employee, Insurer <<<<<<<<<********>>>>>>>>>>>>> 2 RETRAINING RATIONALE: Review Minn. Rule 5220.0750, subp. 2(F) Employee Signature Print or type name Phone number Date Insurer Representative Signature Prin t or type name Phone number Date QRC Signature Print or type name Phone number Date QRC Number INSTRUCTIONS TO QRC NOTE: Retraining is limited to 156 weeks. DISPUTED PLAN: To resolve a disputed Retraining Plan, call the Departments Customer Assistance Unit at (651) 284-5032 and/or file a Rehabilitation Request (see Minn. Rule 5220. 0950). DO NOT SUBMIT A DISPUTED PLAN to the Department without a Rehabilitation Request attached. ACCEPTED PLAN: If all parties are in agreement with (and have signed) this Retraining Plan, submit it to the Department with the required attachments for approval or denial (see Minn. Rule 5220.0750, subp. 5). Approved Denied DLI Representative Signature Print or type name Phone number Date Reason for denial: This material can be made availa ble in different forms, such as large print, Braille or on a tape. To request, call (651) 28 4-5030 or 1-800-342-5354 (DIAL-DLI)/Voice or TDD (651) 297-4198. ANY PERSON WHO, WITH INTENT TO DEFRAUD, RECEIVES WORKE RS COMPENSATION BENEFITS TO WHICH THE PERSON IS NOT ENTITLED BY KNOWINGLY MISREPRESENTI NG, MISSTATING, OR FAILING TO DISCLOSE ANY MATERIAL FACT IS GUILTY OF THEFT AND SHALL BE SENTENCED PURSUANT TO SECTION 609.52, SUBDIVISION 3.
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