Oregon > Workers Comp > Vocational Rehabilitation

Return To Work Plan Direct Employment 1083 - Oregon

Return To Work Plan Direct Employment Form. This is a Oregon form and can be used in Vocational Rehabilitation Workers Comp .
 Fillable pdf Last Modified 10/29/2008
Get this form for FREE as a print-only pdf

Submit to: Department of Consumer & Business Services Workers' Compensation Division 350 Winter St. NE P.O. Box 14480 Salem, Oregon 97309-0405 Date: Counselor (name, phone): VRO (name, city): Return-to-Work Plan; Direct Employment Worker: WCD file no.: Insurer: Claim no.: DOI: 1. Vocational objective(s): S.O.C/D.O.T. code(s): Expected weekly RTW wage: 2. Plan dates: Start date: Projected end date: 3. Specific services required to meet objectives: 4. Responsibilities of worker and counselor unique to this plan: 5. I understand my responsibilities under this plan and have received a copy of the plan support and both sides of this form. I understand that the Workers' Compensation Division may review the plan. Worker Date Plan developer Date Cosigner Date Insurer Insurer phone: Date 6. Comments: For WCD use In conformance with OAR 436-120 Not in conformance Consultant Date Date Date Consultant Date Revised to conform Consultant Optional Consultant 440-1083 (12/07/DCBS/WCD/WEB) 1083 American LegalNet, Inc. www.FormsWorkflow.com Responsibilities under Return-to-Work Plan Worker will do the following: · Maintain regular contact with counselor. · Fully participate in the return-to-work plan services. · Follow up on all job leads in a timely manner. · Accept suitable employment if it is offered and notify counselor immediately. · Promptly inform counselor of any problem that might affect participation. · Meet any responsibilities agreed to in this plan. Counselor will provide the following services in accordance with OAR 436-120: · Provide instruction on job-search skills, as necessary. · Provide job development, as necessary. · Provide timely, accurate progress reports to the insurer. · Meet any other responsibilities agreed to in this plan. Insurer will provide the following services in accordance with OAR 436-120: · Contact the Workers' Compensation Division to schedule a conference if no plan is approved within 45 days of determining the worker entitled to a direct employment plan. · File plan with Workers' Compensation Division. · Meet any other responsibilities agreed to in this plan. 440-1083 (12/07/DCBS/WCD/WEB) American LegalNet, Inc. www.FormsWorkflow.com
Link/Embed this Document

Popular Searches

  1. notice of appearance
  2. petition
  3. probate
  4. order to show cause
  5. order
  6. motion
  7. subpoena duces tecum
  8. termination of parental rights
  9. Summon
  10. subpoena

Bookmark and Share