Re: Employee Name: Claim No.: QRR VERIFICATION OF VOCATIONAL REHABILITATION EXPLANATION INSTRUCTIONS: This form is to be filled out and signed by the Qualified Rehabilitation Representative who meets with the employee and explains his/her rights pursuant to Labor Code §4636(a). This form is to be served on all parties by the QRR. This is to certify that I have personally met with the employee named above and explained to the employee his/her rights and obligations pertaining to vocational rehabilitation in accordance with Labor Code §4636(a). In addition, I have provided the employee with information required by the Division of Workers' Compensation. This meeting occurred on at Street Address (City) (State) (Zip) Copies of this form were sent to: QRR Signature ____________________________________________ Name Date: _________________ Firm Name Street Address List of documents given to employee: City, State, Zip Phone Number QRR Tax ID # RECOMMENDED FORMAT STATE OF CALIFORNIA DWC RU-AC (12/90) 2002 © American LegalNet, Inc.