Maryland > Workers Compensation > Vocational Rehabilitation
Stipulated Rehabilitation Plan VR1 - Maryland
| Stipulated Rehabilitation Plan Form. This is a Maryland form and can be used in Vocational Rehabilitation Workers Compensation . |
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WORKERS COMPENSATION COMMISSION STIPULATED REHABILITATION PLAN Cover Sheet Claimants Name: _______________________________________ WCC Claim #: _____________ The attached WCC rehabilitation plan is submitted to the Commission for: Stipulation: Plans submitted for stipulation must meet the following requirements: 1. Appropriately completed 2. All required signatures provided 3. Signed claimants certification attached 4. All required documentation attached 5. Stated completion date allows at least 10 working days for processing before expiration date File for information: Plans must be filed for information for the following reasons: ? Passed or near the stated completion date ? Plan is not signed by one of or all of the appropriate parties (state the reason why) ? Claimants signed certification is not attached to the plan (state the reason below) Extension of plan: The Commission will not issue stipulation order for extensions of the plans Please complete the following: Date original plan submitted to the Commission: Did the Commission stipulate this plan? Do all parties agree with the extension of plan? Expected length of the proposed extension: Comments: Submitted by: ___________________________________________ Date: Name and title WCC Form VR1 (Revised 3/2000) Page 1 of 9 <<<<<<<<<********>>>>>>>>>>>>> 2 WORKERS COMPENSATION COMMISSION PROPOSED STIPULATED REHABILITATION PLAN Job Placement On-The-Job Training Training Self-employment: For Self-employment opportunities complete the WCC form (VR-4/19/93) I. A. Claimants Information: (Complete for all plans) Please print Claimants Name: __________________________________________ WCC #: Ins. Co. File #: Address: Telephone #: _____________________ Date of Birth: __________ Date of Injury: SS#: TT Benefits: $ SSI, SSDI Benefits: Other: Pre-injury Occupation: Education: Employer: Pre-injury Wages: Anticipated W ages: B. Other Parties Information: (Complete for all plans) Claimants Attorney: Phone #: Insurance Representative/Adjuster: Phone #: Insurance Company: Service Provider Company: Phone #: Practitioner: MCRSP #: Organization: DORS Counselor: Phone #: Counselors Business Address: C. Plan Specifications: (Complete for all plans) 1. Anticipated duration of plan: From: To: 2. Training/OJT: From: To: Placement: from: To: List the proposed job opportunities / recommendations based on order of priority: Position: Projected Wages: Position: Projected Wages: Position: Projected Wages: Position: Projected Wages: Position: Projected Wages: Supporting documents must include sufficient justification for each of the above positions. WCC Form VR1 (Revised 3/2000) Page 2 of 9 <<<<<<<<<********>>>>>>>>>>>>> 3II. Rationale (Complete this section for all plans) In accordance with the Maryland Workers Compensation Law (LE 9-673 (a & b), complete the following: A. Indicate if any of the following tests/assessments have been utilized to develop the recommended position(s) and to provide suitable gainful employment. Mark as many as applicable: RTW FCE Academic interests Employment Hobbies Med./Psych. Evaluation Other (specify): B. Provide a brief summary of the following documentation. Attach additional sheets if needed: MMI: Has the claimants treating physician indicated the claimant has reached maximum medical improvement? Yes: No: If yes, date : If no, explain the condition for the claimants involvement in vocational activities: RTW: Is the claimant released to return to work by the treating physician? Ye No: s: If no, explain the condition for the claimants involvement in vocational activities: Nature and Extent of Disability (FCE): Briefly indicate the limitations and functional capacities of the claimant: Vocational Assessment: Using the definition of suitable gainful employment, briefly list and analyze the results of the claimants academic, interests, hobbies, social activities, and other factors which were considered in making the job recommendations/goals indicated in this plan: WCC Form VR1 (Revised 3/2000) Page 3 of 9 <<<<<<<<<********>>>>>>>>>>>>> 4 Employment: Briefly describe the current and future condition of the labor market pertaining to the recommended job opportunities: Analysis of future earning capacities: Incentives and income of the claimant in comparison with the pre injury earnings, income, interests and incentives consistent with the definition of suitable gainful employment. Present justification for job opportunities recommended: C. Attach copies of pertinent documents indicated above. The documentation attached must be pertinent to the job opportunities listed in section I-C. Do not attach any testing worksheets, explanation of terminology, guide for coring tests or other unrelated materials such as worksheets for interest tests or other subjective evaluations. WCC Form VR1 (Revised 3/2000) Page 4 of 9 <<<<<<<<<********>>>>>>>>>>>>> 5 A. Job Placement: 1. Goals and objectives: 2. Claimants Responsibilities: 3. Counselors Responsibilities: 4. Insurer/Employers Responsibilities: 5. Estimated Cost of Equipment and tools (if any): a. $ b. $ c. $ d. $ Total: WCC Form VR1 (Revised 3/2000) Page 5 of 9 <<<<<<<<<********>>>>>>>>>>>>> 6B. On-The Job Training: 1. Job Title: _________________________ Wage (Beginning of training) $___________ Wage (Beginning of employment) $___________ Jobs physical and education requirements: ______________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ 2. Employer information: Name of Company/business: ______________________________________ Address:_________________________________________________________________________ Contact person: ___________________________________ Phone #: ________________________ 3. O.J.T. objectives: ____________________________________________________________________________________ ____________________________________________________________________________________ 4. Claimants Responsibilities: 5. Counselors Responsibilities: ____________________________________________________________________________________ 6. Insurer/Employers Responsibilities: 7. O.J.T. Trainers Responsibilities: ____________________________________________________________________________________ 8. Cost of Wages, Equipment and tools (if any): a. $ b.
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