KANSAS DEPARTMENT OF LABOR www.dol.ks.gov Page 1 of 2 REHABILITATION PLAN K-WC-R 93-3B (9-13) Claimant: ________________________________________________ Social Security number: _____________________ Employer: ________________________________________________________________________________________ Street: __________________________________ City: ______________________ State: _______ ZIP: _____________ Employer contact: ____________________________________________________ Phone: _______________________ Weekly earnings at date of accident: $ _____________________ Estimated weekly earnings at plan completion: $ __________________ Type of plan: Return to work - same employer (same, modified or different job) Job placement Re-education or training Vocational goal: Services: 1. Provided by: ________________ 2. _______ ____________________ Start : ___________ End : __ ______ Provided by: ________________ 3. _______________ ____________ Start : ___________ End : _ _______ Provided by: _____________ _____________________________ __ Start : ___________ End : __ _______ Anticipated number of weeks for plan completion: _____ DIVISION OF WORKERS COMPENSATION 401 SW Topeka Blvd., Suite 2, Topeka, KS 66603-3105 · Phone: (785) 296-4000, ext. 2152 American LegalNet, Inc. www.FormsWorkFlow.com KANSAS DEPARTMENT OF LABOR Rehabilitation Plan K-WC-R 93-3B (9-13) Page 2 of 2 Responsibilities for completing plan/assessing progress: A. Claimant: B. Qualified rehabilitation professional: The undersigned agree to this vocational plan. Claimant signature: ________________________________________________________ _____ Date: _____________ Counselor signature: ______________________________________________________ _ _____ Date: _____________ Insurance carrier or employer signature: ___________________________________ ___ ______ Date: ____________ Medical documentation of claimant's functional restrictions must be attached. cc: DIVISION OF WORKERS COMPENSATION 401 SW Topeka Blvd., Suite 2, Topeka, KS 66603-3105 · Phone: (785) 296-4000, ext. 2152 American LegalNet, Inc. www.FormsWorkFlow.com