Maryland > Workers Compensation > Vocational Rehabilitation
Closure Report VR-2 - Maryland
| Closure Report Form. This is a Maryland form and can be used in Vocational Rehabilitation Workers Compensation . |
|
||||||
 Get this form for FREE as a print-only pdf |
|||||||
|
WORKERS COMPENSATION COMMISSION REHABILITATION OFFICE 10 - BTEESTR OREIMLTBA STEA A LTIMORE, MD 2141-16202 CLOSURE REPORT WCC#_________________ Claimants name: Date of r eport:________________ Date of referral for services: _________________ Date of termination of services: Practitioner: Cert./Reg. Numbe_____________r ________ Isun rance.: ___________________________________________________________________________ Have all parties been notified of termination of services within 5 working days? Yes _____ No:_______ If No explain why: Rehabilitation services provided: Enter service code(s) 01. Vocational rehabilitation counseling/coordination 02. Vocational evaluation 03. Vocational assessment 04. Medical case management/coordination Programs provided: Enter service code(s) 11. Direct job placement 12. On-The-Job Training program (duration of training) 13. Self employment 14. Job-club 15. FCE 19. Other ______________________ 16. Work hardening ___________________________ 17. Pain management programs ___________________________ 18. Job modification Reason for termination: Enter appropriate code 21. Returned to work with the same employer, same job 22. Returned to work with the same employer different job If returned to work, complete the 23. Returned to work with a new employer, same occupation following: 24. Returned to work with a new employer, different occupation 25. Self employment Pre-injury weekly wages: _________ Wages upon re-employmen _______ t: 26. Return to work is not feasible (Explain) 27. Claimant declined rehabilitation services 28. Claimant was not actively participating in the rehabilitation program 29. Claimant moved out of state 30. Claimant declined job offers that were within the scope of the rehabilitation plan 31. Other: Comments/Explanations: WCC form VR-2 )02001/ 1Rev(
|
|||||||
