STATE OF CALIFORNIA DEPARTMENT OF INDUSTRIAL RELATIONS DIVISION OF INDUSTRIAL ACCIDENTS REHABILITATION BUREAU INSTRUCTIONS: This form is to be used only when the employer fails to voluntarily initiate the provision of vocational rehabilitation services and the employee can substantiate the need for such services. This form is also to be used to request a Bureau determination for reinstatement of vocational rehabilitation benefits. The form must be accompanied by all medical and vocational reports and any other pertinent information not previously submitted to the Bureau. The request must be sent to the appropriate Bureau office and served on the parties. If a Rehabilitation Bureau case number has not been assigned, attach a completed Case Initiation Document (DIA Form RB-101). Do not use this form when liability for the injury is in dispute. EMPLOYEE NAME: (First) (Middle) (Last) REQUEST FOR ORDER OF REHABILITATION BENEFITS REHAB BUREAU USE ONLY RB CASE #: WHEN EMPLOYER INITIALLY FAILS TO PROVIDE VOCATIONAL REHABILITATION BENEFITS The employee claims that the employer failed in it's obligation to voluntarily provide vocational rehabilitation services because: The employee can substantiate his or her medical eligibility as a qualified injured worker in the report of dated / / . Describe the employee's job duties at the time of injury. Explain why the employee is unable to perform his or her job at the time of injury. Did the employee request the employer to provide vocational rehabilitation services? Has the employer/insurer accepted this claim? Has liability for the injury been found by the WCAB? Did the employer provide vocational rehabilitation services? On what date should the employer have provided vocational rehabilitation services? Does the employee wish to choose his or her qualified rehabilitation representative? If answer is yes, enter name: Date last worked: / / YES YES YES YES YES / / / / / / / / NO NO NO NO NO Date of last payment of temporary disability: / / WHEN EMPLOYEE IS REQUESTING REINSTATEMENT OF VOCATIONAL REHABILITATION BENEFITS The employee requests that the Bureau determine his or her entitlement to reinstatement of vocational rehabilitation benefits because: How does the employee substantiate this request? DATE OF APPROVAL OF COMPROMISE & RELEASE OR FINDING OF PERMANENT DISABILITY BY THE APPEALS BOARD DATE OF INJURY: / / / / STATEMENT OF EMPLOYEE In making this request, the employee states that he or she is in need of vocational rehabilitation services, will accept such services and is now able to participate in the provision of such services. Copies of this notice have been sent to: EMPLOYEE SIGNATURE: EMPLOYEE REPRESENTATIVE'S SIGNATURE (if represented): DATE: / DIA FORM RB-104 / 2002 © American LegalNet, Inc.