Mail or fax to: Department of Labor and Industry Worker's Compensation Division PO Box 64221 St. Paul, MN 55164-0221 (651) 284-5032 or 1-800-342-5354 Fax: (651) 284-5731 Rehabilitation Consultation Report Print in ink or type Enter dates in MM/DD/YYYY format RC0 1 DO NOT USE THIS SPACE 1. WID number or SSN 3. Employee name 4. Employee address City 6. Employer name 9. Insurer claim number 10. Insurer/self-insurer/TPA 11. Insurer address City 12. Claim representative 2. Date of injury State ZIP code 5. Employee phone # 8. Employer phone # 7. Employer contact 14. QRC name 15. QRC firm 16. QRC address State ZIP code City 17. QRC # 18. QRC firm # State ZIP code 13. Claim rep phone # 19. QRC phone # 20. In my opinion, the employee is permanently precluded or likely to be permanently precluded from engaging in the employee's usual and customary occupation or from engaging in the job the employee held at the time of injury. 21. In my opinion, the employee is reasonably expected to return to suitable gainful employment with the date-ofinjury employer. 22. In my opinion, the employee is reasonably expected to return to suitable gainful employment through the provision of rehabilitation services, considering the treating physician's opinion of the employee's work ability. 23. I have consulted with the date-of-injury employer regarding the above issues. 24. Check Box A, B or C as applicable: Yes Yes Yes Yes No No No No A. In my opinion the employee is a "qualified employee" and eligible for rehabilitation services at this time according to Minn. Rules 5220.0100, subp. 22. B. In my opinion the employee is not a qualified employee and "is not" eligible to receive rehabilitation services at this time according to Minn. Rules 5220.0100, subp. 22. C. The parties have informed me that they wish to initiate statutory rehabilitation services at this time. ATTACH A NARRATIVE REPORT EXPLAINING THE BASIS FOR YOUR DETERMINATION 25. Date of first in-person or telephone meeting QRC Signature or QRC Supervisor (if applicable) QRC Intern Signature (if applicable) QRC: This form, along with a narrative report and the Rehabilitation Rights and Responsibilities of the Injured Worker form, must be received by the Department of Labor and Industry within 14 days of the date in Box 25 (the first in-person meeting or the first telephone conference) (Minn. Rule 5220.0130). If the employee is eligible for rehabilitation services, a Rehabilitation Plan (R-2) must be developed and circulated to the parties within 30 days of the initial meeting and filed with the Department within 45 days of the initial meeting (Minn. Rule 5220.0410). Employee: If you disagree with or have questions about the information provided on this form, you are encouraged to contact the QRC and insurer to discuss any concerns. If your concerns are not resolved, you may call the Department at (651) 284-5032 or 1-800-3425354, or request a determination by filing a Rehabilitation Request with the Department. This material can be made available in different forms, such as large print, Braille or audio. To request, call (651) 284-5032 or 1-800-342-5354/Voice or TDD (651) 297-4198. ANY PERSON WHO, WITH INTENT TO DEFRAUD, RECEIVES WORKERS' COMPENSATION BENEFITS TO WHICH THE PERSON IS NOT ENTITLED BY KNOWINGLY MISREPRESENTING, MISSTATING, OR FAILING TO DISCLOSE ANY MATERIAL FACT IS GUILTY OF THEFT AND SHALL BE SENTENCED PURSUANT TO SECTION 609.52, SUBDIVISION 3. MN RC01 (5/16) American LegalNet, Inc. www.FormsWorkFlow.com cc: Employee, Employer, Insurer, and Attorney(s)