VR-37E2 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 ­ PLAN OR PLANS 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 Unemployed N/A 2 Date of injury: AWW on date of injury: Date of MMI: Number of days services on hold: Employment start date: Job title at case closure: Number of hours worked per week: N/A N/A N/A 3 4 5 6 7 8 9 10 11 12 14 Hourly wage at case closure: 13 CLOSURE REASON(S) (Check all that apply) Plan(s) approved - completed Number of plans______ Plan(s) approved - not completed/cancelled Number of plans______ Plan(s) not approved/denied Number of plans______ Employee returned to work Employee agreed to a lump sum settlement or release of liability Other (explanation required): __________________________________________________________________ 15 SERVICES PROVIDED (Check all provided services) Initial interview with employee Vocational evaluation/assessment Counseling and guidance Job seeking skills training Job modification Job analysis Labor market survey Labor market research VR plan developed/not implemented Coordinated/monitored formal training 16 Coordinated/monitored job placement Coordinated/monitored OJT Coordinated/monitored supportive service(s) GED ELL ABE Computer skills Other__________________________________ 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: American LegalNet, Inc. www.FormsWorkFlow.com (6/16) Case Closure Report ­ Plan or Plans Proposed Instructions and Descriptions This form is to be filed in any case in which a vocational rehabilitation plan or plans were submitted to the court's vocational rehabilitation section for approval, regardless of whether the plan(s) was approved and regardless of whether the plan(s) was successfully completed. 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 as identified on the VR plan form. 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 employed 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 case 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. Plan(s) approved ­ completed - Indicate number of plans approved and completed. Plan(s) approved ­ not completed - Indicate number of plans approved and not completed. Plan(s) not approved ­ denied - Indicate number of plans not approved/denied. 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. Other- Above reasons do not apply. Provide a thorough explanation on this form or attachment. 15) Services provided - Select all services that have been provided. Initial interview with employee - VR Counselor initial interview with the 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 before, during, and/or after the plan(s). 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. American LegalNet, Inc. www.FormsWorkFlow.com 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 Implemented - A VR plan was developed for the employee but not implemented du