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Vocational Rehabilitation Plan DWC-RU-102 - California
| Vocational Rehabilitation Plan Form. This is a California form and can be used in General Workers Comp . |
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REHABILITATION USE ONLY VOCATIONAL REHABILITATION PLAN Social Security Number Employee Name Address Employer Name Address City, State, Zip Date of Injury Employee Representative Firm Name Address City, State, Zip Firm Name Address (Street, City, State, Zip) Phone No. Claim Number (Last) (Street) (First) (City) WCAB Number (MI) (State) Rehab Unit Number Date of Birth (Zip) Insurance Company Name; Or, if Self-Insured, Certificate Name Adjusting Agency Name (if adjusted) Claims Mailing Address City, State, Zip Employer Representative Firm Name Address City, State, Zip Phone No. Phone No. Qualified Rehabilitation Representative Representative Name Phone No. SECTION A OCCUPATION AT INJURY EARNINGS AT INJURY DESCRIBE TYPE OF INJURY AND MEDICAL RESTRICTIONS (both industrial and non-industrial. Also identify medical report relied upon): SUMMARY OF EMPLOYEE'S EDUCATIONAL AND VOCATIONAL BACKGROUND AND EXPLANATION OF HOW TRANSFERRABLE SKILLS HAVE BEEN USED IN SELECTION OF THE PLAN OBJECTIVE: REHAB UNIT APPROVAL IS REQUIRED DUE TO: Check one: ____ Unrepresented Injured Worker ____ Pre '94 Dates of Injury Initials ____ QRR Waiver ____ Discretionary Monies (Voc. Rehab.) §10133.13 American LegalNet, Inc. www.USCourtForms.com Mandatory Format State of California DWC Form RU-102 (1/03) SECTION B VOCATIONAL OBJECTIVE ESTIMATED WEEKLY EARNINGS UPON COMPLETION Type of Plan With Same Employer 1. Modified Job 2. Alternative Work With New Employer 3. Direct Placement 4. On-The-Job Training 5. Educational Training 6. Self-Employment DESCRIBE NATURE AND EXTENT OF REHABILITATION PLAN: DATE VOCATIONAL FEASIBILITY DETERMINED:________________________ PLAN COMMENCEMENT DATE:__________________________ EXPECTED COMPLETION DATE (Including placement assistance):______________________ #WEEKS OF TRAINING______________________#DAYS OF PLACEMENT ASSISTANCE INITIALS (Voc. Rehab.) §10133.13 American LegalNet, Inc. www.USCourtForms.com Mandatory Format State of California DWC Form RU-102 (1/03) BUDGET FOR VOCATIONAL REHABILITATION PLAN EXPENDITURES Identify incurred and estimated costs for this rehabilitation plan. For injuries on or after 1/1/94, the maximum expenditure for vocational rehabilitation expenses shall not exceed $16,000. RESOURCES TO EMPLOYEE $_____________Weekly VRMA Rate $_____________withheld for attorney fees; $____________Payment to employee Total: $ _________________ VRMA/VRTD paid prior to plan (including attorney fees) Dates: From ____________to____________ VRMA/VRTD to be paid during plan (including attorney fees) Dates: From ___________to_____________ Total: $ _________________ Transportation Expenses to be paid as follows: $____________per___________ Total: $ _________________ PLAN EXPENDITURES Training/Tuition fees, if any (specify recipient): $_____________ Total: $ _________________ Other Costs (specific type, recipient and method of payment) ______________________________ ______________________________ ______________________________ ______________________________ $______________ / $______________ / $______________ / $______________ / _____________ _____________ _____________ _____________ Total: Total: Total: Total: $ $ _________________ _________________ $__________________ $__________________ FEES FOR EVALUATION, PLAN DEVELOPMENT & PLACEMENT (List Evaluation and Plan Development fees to date and estimated fees for Plan Monitoring and Placement) Phase I: Phase II Evaluation $_________________ DOIs on /after 1/1/94 where VR was initiated on/after 1/1/98 Phase A: Phase B $____________________ $____________________ Total: $___________________ $___________________ Plan Development $_________________ Plan Monitoring $_________________ $_________________ Phase III Placement TOTAL ESTIMATE OF PLAN EXPENDITURES: ADDITIONAL RESOURCES TO EMPLOYEE Permanent Disability Supplement paid to date: $_______________ / Week Permanent Disability Supplement to be paid: $_______________ / Week Total: Total: $___________________ $___________________ Other resources to be provided to employee (identify source and amount): _____________________________ _____________________________ $_______________ / ___________ $_______________ / ___________ Total: Total: $___________________ $___________________ SECTION C 1. List results of vocational testing, if any, and how they support the vocational objective: 2. Describe why this employee will be employable in the vocational objective of this plan. Include assessment of labor market. INITIALS (Voc. Rehab.) §10133.13 American LegalNet, Inc. www.USCourtForms.com Mandatory Format State of California DWC Form RU-102 (1/03) SECTION D RESPONSIBILITIES OF THE CLAIMS ADMINISTRATOR: The claims administrator shall provide in a timely manner all vocational services and benefits necessitated by the agreed upon vocational rehabilitation plan and as required by the Labor Code. I verify that the insurer does not have a proprietary interest in the rehabilitation provider or facilities used in the development or implementation of this plan. Other: _______________________________________________ Signature RESPONSIBILITIES OF THE EMPLOYEE: The employee shall be available and reasonably cooperate in the provision of vocational rehabilitation services. The employee shall arrive on time and participate in all scheduled activities; if for any reason the employee does not, he or she must immediately provide an explanation to the Qualified Rehabilitation Representative. The employee shall follow the requirements of all facilities and persons providing vocational rehabilitation services. The employee shall notify the Qualified Rehabilitation Representative about anything that may interfere with scheduled completion of this plan. Other SECTION E 1. VERIFICATION OF THE QUALIFIED REHABILITATION REPRESENTATIVE This plan was developed by me as the Qualified Rehabilitation Representative or as an Independent Vocational Evaluator. It is my opinion that the services contained in this plan will provide the employee with the opportunity to return to suitable gainful employment. 2. The employee was not referred for services for evaluation, education or training to a facility in which I, my spouse, my employer or co-employee has a proprietary interest or which I, my spouse, my employer or co-employee has a contractual relationship. Signature Date Firm Name & Address SECTION F PLAN AGREEMENT Signature of the claims administrator and employee on this plan shall be deemed to be an agreement that claims adminis
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