REHABILITATION USE ONLY VOCATIONAL REHABILITATION PLAN Social Security Number Employee Name Address WCAB Number (Last) Rehab Unit Number (First) (MI) (Street) (City) Date of Birth (State) (Zip) Employer Name Insurance Company Name; Or, if Self-Insured, Certificate Name Address Adjusting Agency Name (if adjusted) City, State, Zip Claims Mailing Address Date of Injury Claim Number City, State, Zip Phone No. Employee Representative Employer Representative Firm Name Firm Name Address Address City, State, Zip Phone No. City, State, Zip Phone No. Qualified Rehabilitation Representative Representative Name Firm Name Address (Street, City, State, Zip) Phone No. SECTION A OCCUPATION AT INJURY EARNINGS AT INJURY DESCRIBE TYPE OF INJURY AND MEDICAL RESTRICTIONS (both industrial and non-industrial. Also identify medical report relied upon): SUMMARY OF EMPLOYEE'S EDUCATIONAL AND VOCATIONAL BACKGROUND AND EXPLANATION OF HOW TRANSFERRABLE SKILLS HAVE BEEN USED IN SELECTION OF THE PLAN OBJECTIVE: REHAB UNIT APPROVAL IS REQUIRED DUE TO: Check one: ____ Unrepresented Injured Worker ____ Pre '94 Dates of Injury Initials ____ QRR Waiver ____ Discretionary Monies (Voc. Rehab.) §10133.13 American LegalNet, Inc. www.USCourtForms.com Mandatory Format State of California DWC Form RU-102 (1/03) SECTION B VOCATIONAL OBJECTIVE ESTIMATED WEEKLY EARNINGS UPON COMPLETION Type of Plan With Same Employer With New Employer 1. Modified Job 3. Direct Placement 2. Alternative Work 4. On-The-Job Training 5. Educational Training 6. Self-Employment DESCRIBE NATURE AND EXTENT OF REHABILITATION PLAN: DATE VOCATIONAL FEASIBILITY DETERMINED:________________________ PLAN COMMENCEMENT DATE:__________________________ EXPECTED COMPLETION DATE (Including placement assistance):______________________ #WEEKS OF TRAINING______________________#DAYS OF PLACEMENT ASSISTANCE INITIALS (Voc. Rehab.) §10133.13 American LegalNet, Inc. www.USCourtForms.com Mandatory Format State of California DWC Form RU-102 (1/03) BUDGET FOR VOCATIONAL REHABILITATION PLAN EXPENDITURES Identify incurred and estimated costs for this rehabilitation plan. For injuries on or after 1/1/94, the maximum expenditure for vocational rehabilitation expenses shall not exceed $16,000. RESOURCES TO EMPLOYEE $_____________Weekly VRMA Rate $_____________withheld for attorney fees; $____________Payment to employee VRMA/VRTD paid prior to plan (including attorney fees) Dates: From Total: From _________________ Total: $ _________________ Total: $ _________________ Total: $ _________________ ____________to____________ VRMA/VRTD to be paid during plan (including attorney fees) Dates: $ ___________to_____________ Transportation Expenses to be paid as follows: $____________per___________ PLAN EXPENDITURES Training/Tuition fees, if any (specify recipient): $_____________ Other Costs (specific type, recipient and method of payment) ______________________________ $______________ / _____________ Total: $ _________________ ______________________________ $______________ / _____________ Total: $ _________________ ______________________________ $______________ / _____________ Total: $__________________ ______________________________ $______________ / _____________ Total: $__________________ FEES FOR EVALUATION, PLAN DEVELOPMENT & PLACEMENT (List Evaluation and Plan Development fees to date and estimated fees for Plan Monitoring and Placement) Phase I: Evaluation Phase II Plan Development $_________________ Phase A: $____________________ Plan Monitoring $_________________ Phase B $____________________ Placement $_________________ Phase III $_________________ DOIs on /after 1/1/94 where VR was initiated on/after 1/1/98 Total: TOTAL ESTIMATE OF PLAN EXPENDITURES: $___________________ $___________________ ADDITIONAL RESOURCES TO EMPLOYEE Permanent Disability Supplement paid to date: $_______________ / Week Total: $___________________ Permanent Disability Supplement to be paid: Total: $___________________ $_______________ / Week Other resources to be provided to employee (identify source and amount): _____________________________ $_______________ / ___________ Total: $___________________ _____________________________ $_______________ / ___________ Total: $___________________ SECTION C 1. List results of vocational testing, if any, and how they support the vocational objective: 2. Describe why this employee will be employable in the vocational objective of this plan. Include assessment of labor market. INITIALS (Voc. Rehab.) §10133.13 American LegalNet, Inc. www.USCourtForms.com Mandatory Format State of California DWC Form RU-102 (1/03) SECTION D RESPONSIBILITIES OF THE CLAIMS ADMINISTRATOR: The claims administrator shall provide in a timely manner all vocational services and benefits necessitated by the agreed upon vocational rehabilitation plan and as required by the Labor Code. I verify that the insurer does not have a proprietary interest in the rehabilitation provider or facilities used in the development or implementation of this plan. Other: _______________________________________________ Signature RESPONSIBILITIES OF THE EMPLOYEE: The employee shall be available and reasonably cooperate in the provision of vocational rehabilitation services. The employee shall arrive on time and participate in all scheduled activities; if for any reason the employee does not, he or she must immediately provide an explanation to the Qualified Rehabilitation Representative. The employee shall follow the requirements of all facilities and persons providing vocational rehabilitation services. The employee shall notify the Qualified Rehabilitation Representative about anything that may interfere with scheduled completion of this plan. Other SECTION E 1. VERIFICATION OF THE QUALIFIED REHABILITATION REPRESENTATIVE This plan was developed by me as the Qualified Rehabilitation Representative or as an Independent Vocational Evaluator. It is my opinion that the services contained in this plan will provide the employee with the opportunity to return to suitable gainful employment. 2. The employee was not referred for services for evaluation, education or training to a facility in which I, my spouse, my employer or co-employee has a proprietary interest or which I, my spouse, my employer or co-employee has a contractual relationship. Signature Date Firm Name & Address SECTION F PLAN AGREEMENT Signature of the claims administrator and employee on this plan shall be deemed to be an agreement that claims administrator and employee intend to comply with all the plan's provisions. Failure of the claims administrator to provide in a timely manner all services required by the plan may result in the employee being entitled to additional services. Failure of the employee to comply with the provisions and schedules developed for this plan may result in termination of the employer's liability for rehabilitation services. I have read and understand all four pages of this plan and agree with all of the plan's provisions. NAME OF EMPLOYEE SIGNATURE DATE NAME OF EMPLOYEE REPRESENTATIVE (if any): DATE SIGNATURE PERSON AUTHORIZING THE PROVISION OF THIS PLAN ON BEHALF OF THE EMPLOYER/CLAIMS ADMINISTRATOR NAME SIGNATURE DATE PERSONS SIGNING THIS SECTION SHALL ALSO INITIAL THE OTHER THREE PAGES IN THE INITIAL BOX (Voc. Rehab.) §10133.13 American LegalNet, Inc. www.USCourtForms.com Mandatory Format State of California DWC Form RU-102 (1/03) Rehabilitation Unit California Division of Workers’ Compensation Form RU-102 * VOCATIONAL REHABILITATION PLAN PLANS FOR REPRESENTED EMPLOYEES INJURED ON OR AFTER 1/1/94 Purpose: To document objectives and methods to be used to implement a proposed rehabilitation plan. Submitted by: Claims Administrator When submitted: The Claims Administrator submits the form with a RU-105 at the completion of the plan. Where submitted: With the applicable Rehabilitation Unit district office. The Rehabilitation Unit’s venue is the same as the WCAB. If no WCAB case exists, file with a Rehabilitation Unit within the county where the injured employee resides. Form completion: See the following page for information on properly completing the form. Please note: This form must be completed using type no smaller than 10 point. All information must be contained within the section provided. Accompanying documents: Within 10 days of plan completion, submit the RU-102 along with a RU-105 Notice of Termination. Medical and vocational reports should not be attached. Rehabilitation Unit action: Statistical recording. Copy: All parties PLANS FOR UNREPRESENTED EMPLOYEE OR WITH A QRR WAIVER AND ALL PLANS FOR EMPLOYEES INJURED BEFORE 1/1/94 Purpose: To document objectives and methods to be used to implement a proposed rehabilitation plan. American LegalNet, Inc. www.USCourtForms.com Submitted by: Claims Administrator When submitted: Immediately upon development of a rehabilitation plan which has been agreed to by the parties. If a waiver of Qualified Rehabilitation Representative is requested, whether represented or not, the plan must be submitted for approval. Where submitted: With the applicable Rehabilitation Unit district office. The Rehabilitation Unit’s venue is the same as the WCAB’s. If no WCAB case exists, file with a Rehabilitation Unit within the county where the injured employee resides. Form completion: See the following page for information on properly completing the form. Please note: This form must be completed using type no smaller than 10 point. All information must be contained within the section provided. Accompanying documents: Include all supporting medical and vocational reports not previously submitted. Rehabilitation Unit action: If disapproval is not made within 30 days of a properly documented plan, the plan is deemed approved. A notice of approval will issue in instances where disapproval previously issued. Copy: All parties. INFORMATION ON HOW TO PROPERLY COMPLETE THE FORM RU-102 Form completion: Submit only if the employee is a Qualified Injured Worker. The RU-102 is prepared by a Qualified Rehabilitation Representative (QRR). In filing out the form, avoid continuation of information to additional sheets. An extension of the information requested on the RU-102 to additional sheets should be limited to only the situation where there is an OJT agreement which describes the responsibilities of the parties and details of training. Page 1; The QRR completes the required information. The box in the lower left hand corner are for the parties to initial to show their agreement with the plan. Employee level of participation must be described. Page 2: The QRR completes the information and the parties initial the page. The RU-102 is used for modified or alternative work plans when the offer of modified or alternate work is made subsequent to the initiation of rehab services. The box in the lower left hand corner is for the parties to initial to show agreement. If training, education, or tutoring is American LegalNet, Inc. www.USCourtForms.com a part of the plan, the counselor must select a facility or program approved by the council for Private Post Secondary and Vocational Education. Page 3: For injuries before 1/1/94--This page describes expected costs of the plan. There is not a legislatively required limit of $16,000 on total costs. For injuries on or after 1/1/94--The purpose of the budget is to plan the estimated expenditures. The total budget for rehabilitation services may not exceed $16,000 including QRR fees. For QRR's fees, please refer to the fee schedule in the administrative rules. This page may be helpful as a counseling tool to show the injured worker that greater expenditures in one area must be balanced with savings in others areas or the development of additional monetary resources. Description of specific items on Page 3 VRMA/VRTD to date - refers to the rate and sum of VRMA payments made since the claims administrator sent the notice of potential eligibility and the injured worker requested rehabilitation services. VRMA/VRTD to be paid - refers to the rate and sum of VRMA payments during the plan. If the claims administrator is withholding for attorney fees, the should be calculated along with the actual weekly benefit payment so the worker will know how much he or she actually receives. Any allocation for TRANSPORTATION EXPENSES such as gas money or public transit tickets must be calculated. Any TRAINING/TUITION FEES and the training provider must be listed. OTHER COSTS - such as clothing, tools, books, babysitting, relocation costs, or any other plan costs not itemized above on the form should be listed. FEES FOR EVALUATION, PLAN DEVELOPMENT AND PLACEMENT and other expenditures from the fee schedule must be listed. To insure that total plan costs do not exceed $16,000 add the following: 1) 2) 3) 4) 5) VRMA/VRTD paid to date -- total VRMA/VRTD to be paid -- total Transportation expenses -- total Total of plan expenditures Total of fees for evaluation, plan development, and placement American LegalNet, Inc. www.USCourtForms.com The injured worker must insure that he can meet his living expenses during the plan by adding the total weekly benefit payment to employee to the permanent disability supplement to be paid and any other confirmed financial resources which are listed. In addition, the injured worker can calculate expenditures for legal and rehabilitation fees by adding the total of amount withheld for attorney fees and the total of fees for evaluation, plan development and placement. Regarding section C-2, labor market surveys are not required. Labor market assessment should include information from the California Occupational Information System if it is available. The box in the lower left hand corner is for the parties to initial to show agreements. Page 4: This is the signature page. Please note: The claims administrator is expected to sign space in Section D as well as Section F. Please note: Any plan, whether the employee is represented or not, which provides funds to the employee to be disbursed at the employee's discretion or on a non-specific basis must be submitted for review to the Rehabilitation Unit to determine whether the plan is in conflict with Labor Code Section 4646 as required by AD 10126(b)(4). American LegalNet, Inc. www.USCourtForms.com