KANSAS DEPARTMENT OF LABOR www.dol.ks.gov VOCATIONAL REHABILITATION CLOSURE REPORT K-WC-R 93-5 (2-14) Vendor: _______________________________________________________________ Vendor number: _____________ Claimant: ________________________________________________ Social Security number: _____________________ Street: __________________________________ City: ______________________ State: _______ ZIP: _____________ Date of accident: _______________ Total cost for vocational rehabilitation services exclusive of weekly compensation, medical costs and medical management ........................................................... $ _________ Total cost paid by insurance company/employer for vendor costs (if different from above) ....... $ _________ Subcontracted costs .................................................................................................................... $ _________ Reason for case closure: 1. Successful return to work (791) 2. Return to work prior to plan (795) 3. Return to work other (796) Date returned to work: _______________ D.O.T. number or job title: __________________________________________ D.O.T. number or job title: __________________________________________ Employer: _________________________________________________________________________________________ Street: __________________________________ City: ______________________ State: _______ ZIP: _____________ Phone: _______________________________ Contact: ____________________________________________________ Average weekly wage (AWW) at date of accident: $ ____________________ Current AWW: $ ____________________ Job description: 4. Plan completed, ability restored (793) 5. Rehabilitation not practical (797) 6. Not entitled to rehabilitation (198) 7. Refused services (194) Explain reason for closure: 8. Settled after plan approved (199) 9. Settled (192) 10. Other closure (190) Counselor signature: __________________________________ QRP number: _______________ Date: ______________ cc: The Division retains the right to enter the appropriate closure code based on a review of the file. 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