Rehabilitation Plan {IC31}

ILLINOIS WORKERS COMPENSATION COMMISSION REHABILITATION PLAN ATTENTION. The employer, in consultation with the injured worker, shall prepare a rehabilitation plan when the employee has been unable towork for more than 120 continuous days or when it can be reasonably dete rmined that the injured worker will be unable to resume his or herregular, pre-injury duties. The plan shall be updated at least every fo ur months while the employee remains incapacitated or until the case isclosed by the Commission. A copy of each document shall be given to the injured worker. See Section 7110.10 of the Commission Rules._______________________________________________ Case # ________ WC ____________________ Employee/Petitioner v. _______________________________________________ Employer/Respondent Attach the most recent medical report and provide an assessment of the m edical care necessary for the petitioner to return to work. ________________________________________________________________________ __________________________________________ ________________________________________________________________________ __________________________________________ Is rehabilitation necessary for the employee to return to work? Yes _ ___ No ____ Explain below. ________________________________________________________________________ __________________________________________ ________________________________________________________________________ __________________________________________ If rehabilitation is necessary, address the need for each of the followi ng: Medical evaluation ________________________________________________________________________ _________________ ________________________________________________________________________ _________________ Vocational evaluation ________________________________________________________________________ _________________ ________________________________________________________________________ _________________ Modified or limited duty________________________________________________________________________ _________________ ________________________________________________________________________ _________________ Retraining ________________________________________________________________________ _________________ ________________________________________________________________________ _________________ Other ________________________________________________________________________ _________________ ________________________________________________________________________ _________________ ___________________________________________________ ___________________________________________________ Signature of petitioner Date Signature of person completing this form Date___________________________________________________ ___________________________________________________ Name of petitioner (please print) Name of person completing this form (please print) IC31 12/04 100 W. Randolph St. #8-200 Chicago, IL 60601 312/814-611 Toll-free 866/352-3033 Web site: www.iwcc.il.gov Downstate offices: Collinsville 618/346-3450 Peoria 309/671-3019 Ro ckford 815/987-7292 Springfield 217/785-7084 American LegalNet, Inc. www.USCourtForms.com