On The Job Training Plan {JA04}

Mail completed copy to: On the Job Training Plan Department of Labor and Industry Please PRINT OR TYPE your responses 443 Lafayette Road North All dates must be entered in MM/DD/YYYY JA 0 4 St. Paul, MN 55155 (651) 284-5030 or 1-800-342-5354 (DIAL-DLI) DO NOT USE THIS SPACE Private or confidential data which you supply on this form will be used to process your workers compensation file. You may refuse to supply the data, but your request may be delayed, or under Minn. Stat. Sec. 176.275, the Department may refuse to accept any formal document that lacks identifying information. This data may be supplied to employers and insurers for the claimed date of injury, the Department of Revenue, the Department of Health and the Workers Compensation Reinsurance Association. It may also be used in workers compensation hearings and for state investigations and statistics. SOCIAL SECURITY NUMBER DATE OF INJURY EMPLOYEE NAME INSURER/SELF-INSURER/TPA INSURER CLAIM NUMBER OJT JOB TITLE OJT EMPLOYER NAME OJT BEGINNING DATE OJT EMPLOYER ADDRESS OJT ENDING DATE CITY STATE ZIP CODE OJT PLAN PROGRESS EVALUATION DATE(S) Does this OJT employer intend to hire the employee upon completion of the OJT? Yes No JOB DESCRIPTION (attach a Job Analysis, or describe the natur e of the work, giving examples of duties) Job must be within the employees physical restrictions. ATTACH MEDICAL REPORT. List the skills the employee w ill acquire through this training: List supplies and tools needed during training (itemize costs): TOTAL COSTS WEEKLY WAGES AND WORKERS COMPENSATION BENEFITS Start of OJT End of OJT Weekly wages paid by OJT Employer Weekly workers compensation benefits paid by Insurer MN JA04 (4/03) -over- cc: Employee, Insurer, OJT Employer <<<<<<<<<********>>>>>>>>>>>>> 2 RATIONALE FOR OJT: see Minn. Rule 5220.0850, subp. 2(N) E: Justification is required for plans EXCEED [NOTE: Justification is required for plans EXCEED Employee Signature Print or type name Phone number Date Insurer Representative Signature Prin t or type name Phone number Date OJT Employer Signature Print or type name Phone number Date OJT Trainer Signature Print or type name Phone number Date QRC Signature Print or type name Phone number Date QRC Number INSTRUCTIONS TO QRC DISPUTED PLAN: To resolve a disputed OJT Plan, call the Departments Cu stomer Assistance Unit at (6 51) 284-5032, and/or file a Rehabilitation Request (see Minn. Rule 522 0.0850, subp. 5). DO NOT SUBMIT A DI SPUTED PLAN to the Department without a Rehabilitation Request attached. ACCEPTED PLAN: If all parties are in agreement with (and have signed) this OJT Plan, submit it to the Department with the required attachments for approval or denial (see Minn. Rule 5220.0850, subp. 4). Approved Denied DLI Representative Signature Print or type name Phone number Date Reason for denial: This material can be made availa ble in different forms, such as large print, Braille or on a tape. To request, call (651) 28 4-5030 or 1-800-342-5354 (DIAL-DLI)/Voice or TDD (651) 297-4198. ANY PERSON WHO, WITH INTENT TO DEFRAUD, RECEIVES WORKE RS COMPENSATION BENEFITS TO WHICH THE PERSON IS NOT ENTITLED BY KNOWINGLY MISREPRESENTI NG, MISSTATING, OR FAILING TO DISCLOSE ANY MATERIAL FACT IS GUILTY OF THEFT AND SHALL BE SENTENCED PURSUANT TO SECTION 609.52, SUBDIVISION 3.