WORKERS COMPENSATION COMMISSION 10 East Baltimore Street - Baltimore, Maryland 21202-1641 Phone: (410) 864-5100 MARYLAND WORKERS COMPENSATION REHABILITATION SERVICE PLAN Job Placement On-The-Job Training Training Self Employment Plan submitted by: DORS Counselor Claimants Attorney Other Claimants Name: WCC #: Address: Phone #: DOB: SS#: DOA: Education: Occupation: Disability: Anticipated duration of the Plan: Start date: Completion date: (Attach details if any) Claimants attorney: P re-Injury Wage: Anticipated Wage: Attorneys phone #: Rehabilitation service provider: Counselor: Counselors phone #: Cert. # Counselors business address: Weekly Temporary Total Benefits: $________ Rehabilitation Plan: 1. Goals and objectives: 2. Summary of rehabilitation assessment and rationale: Attach any document to support the plan such as any test, medical, social, and/or economic information; or any other information used in the development of this plan. WCC Form VR 10R (Rev 11/2000) Page 1 of 2 >>>> 23. Steps to achieve goals: 4. Rehabilitation counselors responsibilities (if applicable): 5. Insurers responsibilities: 6. Claimants responsibilities: 7. Party responsible for providing financial support for this plan: 8. Detailed cost of rehabilitation including training tuition, equipment, books, supplies, working funds, and transportation, etc. $ $ $ $ $ $ $ $ $ $ Total cost: $ Claimants Signature: ______________ Date: Counselors/Attorneys Signature ________ Date: Other Name/Signature: Date: WCC Form VR 10R (Rev 1000/21) Page 2 of 2