KANSAS DEPARTMENT OF LABOR www.dol.ks.gov Page 1 of 2 VOCATIONAL ASSESSMENT K-WC-R 93-3A (9-13) Vendor: _______________________________________ Insurance carrier: ____________________________________ Counselor: ____________________________________________________________ QRP number: ________________ Adjuster: _____________________________________________________________ Phone: _____________________ Claimant: ________________________________________________ Social Security number: _____________________ Street: __________________________________ City: ______________________ State: _______ ZIP: _____________ Phone: _____________________ Date of birth: ___________________ Date of accident (D/A): ____________________ Employer at D/A: _______________________________________Weekly earnings at D/A: $ ______________________ Appraisal of the claimant's previous education, training, qualifications and work experience, including the essential functions performed in the past five years: Current medical status including physical and/or mental limitations imposed by the occupational injury or disease: Does claimant retain the capacity to return to same job, same employer? YES NO If NO, will the employer/insurance company offer a plan to attempt to modify the job or accommodate the injured worker? YES NO 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 Page 2 of 2 Vocational Assessment K-WC-R 93-3A (9-13) Other pertinent considerations: SUMMARY This section should document and provide rationale for the claimant needing or not needing rehabilitation services. Identify the specific problems or obstacles the claimant will have in returning to work and earning a comparable wage: Would a vocational rehabilitation plan be appropriate? If YES, are the parties willing to have a plan developed? YES YES NO NO Unknown If YES, and plan development is agreed upon, submit a rehabilitation plan R93-3B with the signature of all parties. Counselor signature: ____________________________________________________ Date: _______________________ Attach medical and vocational reports to support vocational assessment. 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