2ND 52 WEEK PERIOD Department of Labor and Industries This form must be completed by the Vocational Counselor assigned by either State Fund or Self Insurance. TRANSPORTATION COST ENCUMBRANCE Modification Original **** Counselor is responsible for sending a copy of this form to each vendor **** Claimant: Date Vendor Name Vendor Name Claim Number Vendor Name Vendor Name Total Funds Billing Category and Code Provider No. Provider No. Provider No. Provider No. From: To: From: To: From: To: From: To: Mileage - 0301R Parking - 0302R Bridge & Ferry Tolls - 0303R Commercial Transportation - 0304R Vendor Funds Allocated Dates of Service » » » » » » » » » » » » » Total Transportation Funds Allocated in 2nd 52 Weeks: Mileage Calculation Address training site A Address training site B 1st, Miles in a round trip (Worker's street address to site A by most direct route). 2nd, Multiply miles by the actual x training days. 1st, Miles in a round trip (Worker's street address to site B by most direct route). 2nd, Multiply miles by the actual x training days. 3rd, Multiply total in line 2 by current reimbursement rate x 3rd, Multiply total in line 2 by current reimbursement rate x Reimbursement to site A = Reimbursement to site B = Total reimbursement requested (Site A+Site B) = NOTICE: Please attach a copy of this form to the Injured Worker's Travel Expense Voucher form (yellow), when submitting for reimbursement. Company Phone No. Assigned Vocational Counselor: Date FAX No. Signature For Dept Use Only Vocational Services Specialist Not Recommended Recommended Date Phone No. Signature Supervisor of Industrial Insurance Not Approved Approved Date Phone No. Signature F245-361-000 2nd 52 wk transport cost encumbrance 01-2008 Do not use for workers with training plans approved after 1-1-2008 INDEX: VPLAN American LegalNet, Inc. www.FormsWorkflow.com