Mail or fax to: Department of Labor and Industry Workers' Compensation Division PO Box 64221 St. Paul, MN 55164-0221 (651) 284-5032 or 1-800-342-5354 Fax: (651) 284-5731 R-2 Rehabilitation Plan Print in ink or type Enter dates in MM/DD/YYYY format RE0 1 DO NOT USE THIS SPACE 1. WID number or SSN 2. Date of injury Please fill out this form. You cannot save data typed into this form. Please print the completed form if you would like a copy for your records. 3. Employee name 4. Employee address City 7. Employer name 10. Insurer claim number 11. Insurer/self-insurer/TPA 12. Insurer address City 13. Claim representative 21. Occupation at time of injury 23. Occupational demands Sedentary Light Medium Part time Heavy Full time Very heavy State Zip code State ZIP code 5. Employee phone number 8. Employer contact 15. QRC name 16. QRC firm 17. QRC address City 18. QRC # 19. QRC firm # State ZIP code 6. Date of birth 9. Employer phone number 14. Phone number 22. Pre-injury AWW 20. QRC phone number 27. Highest grade completed (select one) a. No high school diploma or GED b. High school diploma or GED c. Some post-secondary course work d. Post-secondary vocational/technical program e. Bachelor's degree f. Master's, Ph.D. or professional degree 24. Job at date of injury 25. Employee's current work status a. Off work from DOI to start of rehabilitation b. Some work between DOI and start of rehabilitation, not working at start of rehabilitation c. Working at start of rehabilitation 26. Vocational goal a. RTW same employer b. RTW different employer QRC comments 28. Employee may require an interpreter Yes No 29. Date of first consultation in person or telephone meeting (#25 on RCR) Complete all service areas to be provided during this plan Service category 00 - Rehabilitation Consultation 01 - Medical Management Description Report actual consultation costs in the "projected cost" box Projected cost Projected completion date N/A MN RE01 (8/15) American LegalNet, Inc. www.FormsWorkFlow.com Service category 02 - On-Site Job Analysis 03-Coordinate RTW/same ER 04 - Job Modification Description Projected cost Projected completion date 05 - Functional Capacities Evaluation 06 - Transferrable Skills Analysis 07 - Work Evaluation 08 - Work Hardening/Adjustment 09 - Job Seeking Skills Training 10A - Job Development (See instructions to QRC) 10B - Job Placement (See instructions to QRC) 11 - Post Placement/Follow-up 12 Technical/Academic Skills Improvement 13 - Vocational Counseling/Guidance 14 - Vocational Testing 15 - On-the-Job Training 16 - Labor Market Survey American LegalNet, Inc. www.FormsWorkFlow.com 17 - Exploration of Retraining/Formal Retraining 18 - Administrative 19 Preparation/Attendance conference/hearing 20 - Expenses/Other Total projected costs Employee comments (if any) Employer/insurer responsibilities: Minnesota Statutes § 176.102, subd. 9, and Minnesota Rules 5220.1900, subp. 1g · Review, sign and return the R-2 form within 15 days. · Pay for services reasonably required. · Monitor the costs and timeliness of services. Qualified rehabilitation consultant (QRC) responsibilities: Minn. Stat. § 176.102 and Minn. Rules 5220.0100 to .1900 · Do not file the R-2 form with DLI at the same time it is circulated to the parties. · File the R-2 form and narrative report at the following time, whichever time comes first: 1) when the parties have all signed it; 2) 15 days after circulation to the parties (or 15 days after recirculation if one of the parties proposed a change in the plan); or 3) 45 days after the first in-person contact with the employee. · If all signatures are not obtained within the filing deadline, file the R-2 form with the signatures obtained and with a letter or other evidence the plan was sent to each nonsigning party. Employee responsibilities · Cooperate with all parties involved and make a good faith effort to participate in the rehabilitation plan. · Attend scheduled activities and appointments, and adhere to reasonable medical advice. To the parties If you disagree with the plan you have 15 days from the receipt of the proposed plan to resolve the disagreement or object to the proposed plan. The objection must be filed with the department on a Rehabilitation Request form. Employee signature QRC signature Date Date Claim representative signature QRC intern supervisor signature Date Date R-2 Rehabilitation Plan Form Information Rehabilitation plan privacy and confidentiality Private or confidential data you supply on this form will be used to process your workers' compensation claim. The data will be used by Department of Labor and Industry staff members who have authorized access to the data and may be used for state investigations and statistics. You may refuse to supply the data, but if you refuse, your claim may be delayed or denied, or the form may be returned to you. The data will be made part of the department's file for your claim and may be supplied to: anyone who has access to the file or the data by authorization or court order; the employer and insurer for your claim; the Office of Administrative Hearings; the Workers' Compensation Court of Appeals; the Departments of Revenue and Health; and the Workers' Compensation Reinsurance Association. Rehabilitation form availability This form and access to the electronic submission format is located at www.dli.mn.gov/WC/WcForms.asp. The form can be made available in different formats, such as large print, Braille or audio. To request, call (651) 284-5032 or 1-800-342-5354. Intent to commit fraud Any person who, with intent to defraud, receives workers' compensation benefits to which the person is not entitled by knowingly American LegalNet, Inc. www.FormsWorkFlow.com misrepresenting, misstating or failing to disclose any material fact is guilty of theft and shall be sentenced pursuant to Minn. Stat. § 609.52, subd. 3. Instructions to QRC Completing the R-2 Rehabilitation Plan Form Purpose: The Rehabilitation Plan form documents the services proposed to be provided to the employee by the QRC and the responsibilities of the QRC, insurer and employee. The form also instructs the parties about how to proceed if there is a dispute regarding the plan and gives information about data privacy and confidentiality. See Minn. Rules 5220.0410. Instructions for items 21 to 24: Enter information about the job the employee had at the time of injury and the physical demands of the job. See Dictionary of Occupational Titles physical