Department of Labor and Industries 1st 52 WEEK PERIOD This form must be completed by the Vocational Counselor assigned by either State Fund or Self Insurance. RETURN TO WORK PLAN TIME ENCUMBRANCE Original **** Counselor is responsible for sending a copy of this form to each vendor **** Date of this request Modification Claim number Assigned Vocational Counselor VRC Provider ID # Vocational counseling firm's name VRC Phone number Injured worker's name Date of injury Address Firm Provider # & branch Home address Phone number City/State ZIP+4 City/State ZIP Type of Modification Plan Dates Requested Change in time frames Effective start date Change in goal Change start date to Change in training site Interrupt plan on Change in costs Restart plan on Continue time loss to LEP to start on Other (specify) LEP to end on End date, 1st 52 weeks Early plan termination Goal Method DOT # Training site Contact person Phone L&I USE ONLY Company Phone No. Assigned Vocational Counselor Date FAX No. Signature For Dept Use Only Vocational Services Specialist Not Approved Approved Date signed Phone No. Signature F245-353-000 1st 52 wk rtw plan time encumbrance 01-2008 For workers with training plans approved after 1-1-2008, use form F245-376-000 INDEX: VPLAN American LegalNet, Inc. www.FormsWorkflow.com