WORKERS’ COMPENSATION COMMISSION STIPULATED REHABILITATION PLAN Cover Sheet Claimant Name: WCC Claim #: The attached WCC rehabilitation plan is submitted to the Commission for: Stipulation: Plans submitted for stipulation must meet the following requirements: 1. 2. 3. 4. 5. Appropriately completed All required signatures provided Signed claimant’s certification attached All required documentation attached Stated completion date allows at least 10 working days for processing before expiration date File for information: Plans must be filed for information for the following reasons: Passed or near the stated completion date Plan is not signed by one of or all of the appropriate parties (state the reason why) Claimant’s signed certification is not attached to the plan (state the reason below) Extension of plan: The Commission will not issue stipulation order for extensions of the plans Please complete the following: Date original plan submitted to the Commission: Did the Commission stipulate this plan? YES Do all parties agree with the extension of plan?? NO YES NO Expected length of the proposed extension: Comments: Submitted by: Name and title WCC Form VR1 (Revised 11/2006) Date Page 1 of 9 American LegalNet, Inc. www.FormsWorkflow.com WORKERS’ COMPENSATION COMMISSION PROPOSED STIPULATED REHABILITATION PLAN Job Placement On-The-Job Training Training Self-employment: For self-employment opportunities complete the WCC form VR-4 I. A. Claimant Information: (Complete for all plans) Claimant’s Name: WCC #: Ins. Co. File #: SS#: Address: City State Telephone #: ZIP Code Date of Birth: TT Benefits: $ Date of Injury: SSI, SSDI Benefits:$ Other:$ Pre-injury Occupation: Education: Employer: Pre-injury Wages: Anticipated Wages: B. Other Parties’ Information: (Complete for all plans) Claimant’s Attorney: Phone # Insurance Company Insurance Representative/Adjuster: Phone #: Service Provider Company: Practitioner: Organization: DORS Counselor: Phone #: MCRSP #: Phone #: Counselor’s Business Address: City State ZIP Code C. Plan Specifications: (Complete for all plans) 1. Anticipated duration of plan - : From: 2. Training/OJT From: To: To: Placement From: To: List the proposed job opportunities / recommendations based on order of priority: Position: Projected Wages: Position: Projected Wages: Position: Projected Wages: Position: Position: Projected Wages: Projected Wages: Supporting documents must include sufficient justification for each of the above positions. WCC Form VR1 (Revised 11/2006) Page 2 of 9 American LegalNet, Inc. www.FormsWorkflow.com II. Rationale (Complete this section for all plans) In accordance with the Maryland Workers’ Compensation Law (LE 9-673 (a & b), complete the following: A. Indicate if any of the following tests/assessments have been utilized to develop the recommended position(s) and to provide suitable gainful employment. Mark as many as applicable: RTW FCE Academic Med./Psych. Evaluation B. Interests Employment Hobbies Other (Specify): Provide a brief summary of the following documentation. Attach additional sheets if needed: MMI: Has the claimant’s treating physician indicated the claimant has reached maximum medical improvement? Yes No If yes, date : If no, explain the condition for the claimant’s involvement in vocational activities: RTW: Is the claimant released to return to work by the treating physician? Yes If no, explain the condition for the claimant’s involvement in vocational activities: No Nature and Extent of Disability (FCE): Briefly indicate the limitations and functional capacities of the claimant: Vocational Assessment: Using the definition of suitable gainful employment, briefly list and analyze the results of the claimant’s academic, interests, hobbies, social activities, and other factors which were considered in making the job recommendations/goals indicated in this plan: WCC Form VR1 (Revised 11/2006) Page 3 of 9 American LegalNet, Inc. www.FormsWorkflow.com Employment: Briefly describe the current and future condition of the labor market pertaining to the recommended job opportunities: Analysis of future earning capacities: Incentives and income of the claimant in comparison with the pre injury earnings, income, interests and incentives consistent with the definition of suitable gainful employment. Present justification for job opportunities recommended: C. Attach copies of pertinent documents indicated above. The documentation attached must be pertinent to the job opportunities listed in section I-C. Do not attach any testing worksheets, explanation of terminology, guide for coring tests or other unrelated materials such as worksheets for interest tests or other subjective evaluations. WCC Form VR1 (Revised 11/2006) Page 4 of 9 American LegalNet, Inc. www.FormsWorkflow.com A. Job Placement 1. Goals and Objectives 2. Claimant’s Responsibilities 3. Counselor’s Responsibilities 4. Insurer/Employer’s Responsibilities 5. Estimated Cost of Equipment and tools (if any): a. $ b. $ c. $ d. $ Total: WCC Form VR1 (Revised 11/2006) Page 5 of 9 American LegalNet, Inc. www.FormsWorkflow.com B. On-The Job Training: 1. Job Title: Wage (Beginning of training) $ Wage (Beginning of employment) $ Job’s physical and education requirements: 2. Employer information: Name of Company/business: Address: City: Contact person: State: ZIP Code: Phone #: 3. O.J.T. Objectives 4. Claimant’s Responsibilities: 5. Counselor’s Responsibilities: 6. Insurer/Employer’s Responsibilities: 7. O.J.T. Trainer’s Responsibilities: 8. Cost of Wages, Equipment and tools (if any): a. $ b. $ c. $ d. $ Total: WCC Form VR1 (Revised 11/2006) Page 6 of 9 American LegalNet, Inc. www.FormsWorkflow.com C. Training: 1. Physical and educational requirements of training: 2. Facility or training provider: Address: City Contact Person: Position: State ZIP Code Phone #: 3. Training objectives: 4. Claimant’s Responsibilities: 5. Counselor’s Responsibilities: 6. Insurer/Employer’s Responsibilities: 7. Cost of Tuition and supplies: a. $ b . $ c. $ d. $ Total: WCC Form VR1 (Revised 11/2006) Page 7 of 9 American LegalNet, Inc. www.FormsWorkflow.com CERTIFICATION I, the undersigned injured worker, do certify that I have read the Vocational Rehabilitation Plan attached and that I understand the following: 1. This plan is an agreement, which outlines each party’s responsibility regarding my vocational rehabilitation. 2. The Insurer will pay rehabilitation benefits equal to weekly temporary total disability benefits and also the expenses of the rehabilitation service. 3. The time frame(s) agreed to by the parties can be extended if necessary by the parties. If the Insurer refuses and I believe I am entitled to more time, I have the right to request a hearing before the Commission to have a Commissioner determine whether services should be continued. 4. I do not have to accept any employment offered to me unless I agree that it is suitable employment, and I am aware that if the Insurer believes the employment is suitable and I have declined it, the Insurer may stop the payment of benefits and assert my non-cooperation. In that event, a hearing may be requested before the Commission to have a Commissioner determine whether the employment offer was suitable employment. 5. The Insurer may stop benefit payments if the Insurer determines that rehabilitation services are no longer necessary or if they determine that I am not cooperating in their rehabilitation efforts. 6. If my benefit payments are stopped for any reason with which I do not agree, I have the right to request a hearing and have a Commissioner decide the issue. 7. I have a right to be an active participant in my rehabilitation and have both the right and the responsibility to express my desires and expectations. 8. I have a right to confer with an attorney regarding the terms of the rehabilitation plan. I HAVE READ THIS CERTIFICATION AND/OR HAVE HAD IT EXPLAINED TO ME, AND I UNDERSTAND ITS PROVISIONS. ___________________________________ Clamant Name WCC Claim No: WCC Form VR1 (Revised 11/2006) Signature DATE: Page 8 of 9 American LegalNet, Inc. www.FormsWorkflow.com Approval Claimant must review and sign the certification (Page 8) prior to signing this plan. Claimant’s certification must not be detached from the plan. Claimant’s acknowledgment: I have I have not reviewed and signed the Claimant’s Certification. This plan has been reviewed and approved by the undersigned parties: ____________________________________________ Claimant Date: Print or type full name __________________________________________ Claimant’s Attorney: Date: Print or type full name __________________________________________ Insurer/Employer Representative: Date: Print or type full name __________________________________________ Insurer/Employer Attorney (if applicable): Date: Print or type full name ____________________________________________ Rehabilitation Counselor Preparing the Plan: Date: Print or type full name _____________________________________________ Training Representative: Date: Print or type full name _____________________________________________ DORS Counselor (if applicable): Date: Print or type full name Date submitted to the Commission for stipulation: WCC Form VR1 (Revised 11/2006) Page 9 of 9 American LegalNet, Inc. www.FormsWorkflow.com