VR-37E1 Nebraska Workers' Compensation Court P.O. Box 98908 Lincoln, Nebraska 68509-8908 (402) 471-3606 (800) 599-5155 When completed, mail to above address or Fax to NEWCC VR Section at (402) 742-8311 or Email to WCC.VocRehabSM@nebraska.gov SUBMIT CASE CLOSURE REPORT­ NO PLAN PROPOSED (See attached instructions) 1 Name of employee: Name of certified VR counselor: Counselor appointment/agreement Date: Date of VR case closure: Employment status at case closure: Employed new employer Employed same employer Unemployed Hourly wage at case closure: N/A 2 Date of injury: AWW on date of injury: Date of MMI: Number of days services on hold: start date: N/A N/A N/A 3 4 5 6 7 8 9 10 Employment 11 Job title at case closure: 12 13 Number of hours worked per week: 14 CLOSURE REASON(S) (Check all that apply) Returned to work Lump sum settlement or release of liability Not entitled to VR services Not interested in VR services Uncooperative/failure to participate 15 Medically unable to participate Permanently totally disabled Other (explanation required) ___________________________________________ ___________________________________________ SERVICES PROVIDED Initial interview with employee Vocational evaluation/assessment Counseling and guidance Job seeking skills training Job modification Job analysis 16 (Check all provided services) VR plan developed/not proposed Labor market research Labor market survey Other services (explanation required): ____________________________________________ ____________________________________________ Counselor Professional Fees: hours billed: ______ hourly rate: $________ total amount billed: $________ JP Specialist Professional Fees: hours billed: ______ hourly rate: $________ total amount billed: $________ Expenses: 17 total amount billed: $________ Date: CERTIFIED COUNSELOR SIGNATURE: (6/16) American LegalNet, Inc. www.FormsWorkFlow.com Case Closure Report ­ No Plan Proposed Instructions and Descriptions This form is to be filed in any case in which vocational rehabilitation services were provided by the counselor but no vocational rehabilitation plan was submitted to the court's vocational rehabilitation section for approval. This form shall be filed within five working days after services are terminated (see instruction #7). 1) Name of employee: Full name of employee. 2) Date of injury: Date of injury reported on "First Report of Injury" filed with the court unless a different date is agreed to by the parties. 3) Name of Certified VR Counselor: Full name of counselor of record, agreed upon/appointed to VR case. 4) AWW on date of injury: Average weekly wage on employee's date of injury per agreement by the parties or ordered by a Judge. 5) Counselor appointment/agreement date: Date certified VR counselor was agreed upon/appointed to VR case. 6) Date of MMI: Date employee reached maximum medical improvement per physician or ordered by a Judge. 7) Date of VR case closure: A case shall be closed within 5 working days after services are terminated. Services shall be considered terminated when services are no longer being actively provided by the counselor and there are no delays due to legal, medical, or other issues beyond the control of the counselor. 8) Number of days services on hold: Include the number of days in which services were not being actively provided due to legal, medical, or other delays beyond the control of the counselor. 9) Employment status at case closure: Choose the status that accurately describes the employee's employment status at time of case closure. Place a check mark in the box indicating if same employer, new employer, or unemployed. If employment status cannot be determined leave both boxes blank and attach a written explanation of the steps taken by the counselor to contact the employee and/or otherwise determine employment status. 10) Employment start date: Indicate employee's employment start date. Place a check mark in the N/A box if the employee is not employed at time of case closure. 11) Job title at case closure: If employed, include the employee's job title at case closure or a term that describes the position held. Place a check mark in the N/A box if the employee is not employed at time of case closure. 12) Hourly wage at closure: Report the employee's hourly wage if employed at time of case closure. Place a check mark in the N/A box if the employee is not employed at time of case closure. 13) Number of hours worked per week: Report the employee's hours worked per week. Place a check mark in the N/A box if the employee is not employed at time of case closure. 14) Closure reason(s): Select the appropriate box(s) by placing a check mark for the reason(s) for case closure. Returned to work - Employee is now working. Lump Sum Settlement or Release of Liability - The parties have agreed to a lump sum settlement or a release of liability. Not entitled to VR Services - VR services were not appropriate for the employee. Not Interested in VR Services - Employee is not interested in VR services. Uncooperative/failure to participate - Employee did not cooperate with the VR Counselor providing services. Medically unable to participate ­ Employee's medical condition(s) precludes participation in VR services. Permanent Total Disability - Employee has been determined to be permanently and totally disabled and, therefore, VR services are not appropriate. Other- Above reasons do not apply. Provide a thorough explanation on this form or attachment. American LegalNet, Inc. www.FormsWorkFlow.com 15) Services provided - Select all services that have been provided. Initial interview with employee - VR Counselor initial interview with employee. Vocational Evaluation/Assessment - an appraisal of the employee's work/training background, general functional capacities, and/or social/behavioral characteristics was performed. Counseling and Guidance - VRC provided vocational counseling and guidance to the employee. Job seeking skills training - VRC provided job seeking skills training to the employee, including how to find job openings, how to apply for jobs, development of a resume, interviewing techniques, and/or other skills. Job Modification - VRC worked with an employer to adjust job duties and/or requirements to work with the employee's permanent restrictions and/or related issues. Job Analysis - Information was gathered about a job for purposes of providing work accommodation recommendations. VR Plan Developed/Not Proposed - A VR Plan was