Closure Report
Download Free Print-Only PDF OR Purchase Interactive PDF Version of this Form
Closure Report Form. This is a Maryland form and can be use in Vocational Rehabilitation Workers Compensation.
Loading PDF...
Tags: Closure Report, VR-2, Maryland Workers Compensation, Vocational Rehabilitation
WORKERS’ COMPENSATION COMMISSION
REHABILITATION OFFICE
10 EAST BALTIMORE STREET - BALTIMORE, MD 21202-1641
WCC#
CLOSURE REPORT
Claimant’s name:
Date of referral for services:
Practitioner:
Date of report:
Date of termination of services:
Cert./Reg. Number
Insurance:
Have all parties been notified of termination of services within 5 working days?
If "NO" explain why:
Yes
No
Rehabilitation services provided: Enter service code(s)
01.
Vocational rehabilitation counseling/coordination
02.
Vocational evaluation
03.
Vocational assessment
04.
Medical case management/coordination
Programs provided: Enter service code(s)
11. Direct job placement
12. On-The-Job Training program (duration of training)
13. Self employment
14. Job-club
15. FCE
19. Other
16. Work hardening
17. Pain management programs
18. Job modification
Reason for termination: Enter appropriate code
21.
Returned to work with the same employer, same job
If returned to work, complete the
22.
Returned to work with the same employer different job
following (numeric, no commas):
23.
Returned to work with a new employer, same occupation
24.
Returned to work with a new employer, different occupation
Pre-injury weekly wages:
25.
Self employment
Wages upon re-employment:
26.
Return to work is not feasible (Explain below)
27.
Claimant declined rehabilitation services
28.
Claimant was not actively participating in the rehabilitation program
29.
Claimant moved out of state
30.
Claimant declined job offers that were within the scope of the rehabilitation plan
31.
Other:
Comments/Explanations
WCC form VR-2 (Rev 11/2000)
American LegalNet, Inc.
www.FormsWorkflow.com
