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 Rehabilitation Rights and Responsibilities of the Injured Worker Print in ink or type Enter dates in MM/DD/YYYY format IW 5 0 DO NOT USE THIS SPACE WID number or SSN Employee name Date of injury The purpose of vocational rehabilitation under Minnesota Statutes § 176.102 is to assist you so that you may return to your former job, to a job related to your former employment or to a job in another work field. The job should be physically appropriate and produce an economic status as close as possible to that which you would have enjoyed without disability. The first step in this return-to-work process is a rehabilitation consultation, an in-person or telephone meeting with a qualified rehabilitation consultant (QRC) to determine if you qualify for rehabilitation services. If the QRC determines you are qualified, the next step is the development of a rehabilitation plan. Your QRC will help you develop and implement this plan and explain the rehabilitation services available to you. Consideration will be given to your former employment, average weekly wage, the current labor market and your qualifications, including transferable skills, previous work history, age, education and interests. You will not be billed for rehabilitation services. Rights of the injured worker Under Minnesota workers' compensation law, you have vocational rehabilitation rights. · You may obtain a list of registered QRCs in your area by visiting the department's website at www.dli.mn.gov/WC/QrcData.asp. For a rehabilitation consultation, the insurer may refer you to a QRC or you may choose your own. If you did not choose the QRC for your consultation, you have up to 60 days after a rehabilitation plan is filed to request a different QRC. You may be entitled to change QRCs at other times as well; call the Alternative Dispute Resolution (ADR) unit at (651) 284-5032 or 1-800-342-5354 if you would like more information. When a QRC first meets or writes to contact you, he or she is required to disclose to you in writing any affiliation or ownership interest between the QRC (or the QRC firm) and your employer, any workers' compensation insurer or adjusting company. The QRC is also required to disclose to you and all parties to a case any affiliation or business referral arrangement, documented or not, between the QRC (or the QRC firm) and any other parties to the case, including attorneys and doctors. A vocational rehabilitation plan may include training and/or formal education. You may request a change in your rehabilitation plan. Your QRC needs your permission to: attend, schedule or cancel medical appointments; discuss your medical care and treatment with your health care providers; or obtain medical records from your health care providers. You may withdraw your permission for your QRC to: attend, schedule or cancel medical appointments; discuss your medical care and treatment with your health care providers; or obtain medical records from your health care providers. The QRC must provide copies of your rehabilitation plan, required rehabilitation reports and progress records, including correspondence prepared or received by the QRC, to you and the other parties and attorneys. An exception is that progress records need to be sent to the employer only upon the employer's request. · · · · · · MN IW05 (10/13) (over) American LegalNet, Inc. www.FormsWorkFlow.com WID number or SSN Date of injury Employee name IW 5 0 · You have the right to request assistance regarding rehabilitation services and other claims issues from the Department of Labor and Industry. If you have questions about vocational rehabilitation services, call the ADR unit at (651) 284-5032 or 1-800-342-5354. If there is a dispute about your eligibility for statutory rehabilitation services or the rehabilitation plan, you may file a Rehabilitation Request form and the department may schedule an administrative conference to resolve the dispute. Responsibilities of the injured worker Under Minnesota workers' compensation law, you have vocational rehabilitation responsibilities. · · You must make a good faith effort to participate in your rehabilitation plan. Failure to do so may result in suspension or termination of your workers' compensation benefits. You must advise your QRC and insurance company of your wage, hours, employer and job title when you return to work with any employer and when your hours or wages change. This is necessary to accurately calculate your wage-loss benefits and to ensure rehabilitation services are appropriate. Failure to accurately report wages earned while receiving workers' compensation benefits may result in civil or criminal consequences. You must cooperate with reasonable medical and rehabilitation examinations and evaluations as ordered by the commissioner or a compensation judge. Failure to do so may result in suspension or termination of your workers' compensation benefits. · Disclosure The statements below are to verify whether you received the documents listed and that the information on this form has been explained to you. You are not required to provide the information requested below or sign this form. Your workers' compensation benefits will not be affected if you choose not to provide the information or sign this form. This form will be filed with the Minnesota Department of Labor and Industry and may also be provided to the Office of Administrative Hearings and law enforcement agencies. Employee, check all that apply: The above information has been explained to me and I have been provided with a copy of this form. I have received written notification from the QRC disclosing: 1) any affiliation, ownership interest or business referral arrangement, whether documented or not, the QRC or QRC firm may have with the employer, workers' compensation insurer, adjusting or servicing company; and 2) any affiliation, business referral or other arrangement with any party, attorney or health care provider in my case. The QRC has informed me that the QRC and the QRC firm do not have any affiliation, ownership interest, business referral or other arrangements with any of the persons described above. Employee signature QRC signature QRC # Date QRC intern supervisor signature Date Date The QRC must sign and date this form at the first in-person or telephone meeting with the emp