Individual Written Rehabilitation Program Form. This is a Massachusetts form and can be use in Workers Comp.
Tags: Individual Written Rehabilitation Program, 151, Massachusetts Workers Comp,
The Commonwealth of Massachusetts Department of Industrial Accidents FORM 151 DIA Board #: 600 Washington Street – 7th Floor, Boston Massachusetts 02111 Info. Line (800) 323-3249 ext. 470 in Mass. Outside Mass. - (617) 727-4900 ext. 470 http://www.mass.gov/dia Page 1 of 2 INDIVIDUAL WRITTEN REHABILITATION PROGRAM Please Print or Type Client Name: _________________________ V.R. Provider: _______________________ Street Address: _________________________ Street Address: _______________________ City, State, Zip: _________________________ City, State, Zip: _______________________ _________________________ _______________________ Tel. Number: _________________________ Tel. Number: _______________________ Date of Birth: _________________________ V.R. Counselor: _______________________ Pre-Injury Wage: $________________________ Insurer: _______________________ Vocational Goal _________________________ Claims Rep.: _______________________ DOT Code: _________________________ Tel. Number: _______________________ Date of Injury: _________________________ FUNCTIONAL LIMITATIONS (with supporting documents i.e. physical evaluation etc.): _________________________________________________________________________________________________ _________________________________________________________________________________________________ LEVEL OF SERVICE - Employment Goal: Job Placement, Job Modification, OJT, Training _________________________________________________________________________________________________ _________________________________________________________________________________________________ VOCATIONAL SERVICES PLANNED & COST: FROM TO ESTIMATED COST Vocational Counseling and Guidance __________ ___________ $_________________ Job Seeking Skills Training (with Resume prep.) __________ ___________ $_________________ Transferable Skills __________ ___________ $_________________ Job Modification (former Employer) __________ ___________ $_________________ Vocational Training (including formal classes) __________ ___________ $_________________ On-the-job Training __________ ___________ $_________________ Job Development & Placement __________ ___________ $_________________ OVER Form 151 - Revised 8/2001 - Reproduce as needed. American LegalNet, Inc. www.USCourtForms.com FORM 151 Page 2 of 2 VOC. SERVICES PLANNED & COST (CONT.): FROM TO ESTIMATED COST Post-Placement Follow-up __________ ___________ $_________________ Transportation __________ ___________ $_________________ Program Completion Date:__________ Total Est. Cost: $_________________ Program Justification: Submit a comprehensive case analysis of the injured worker, including such things as possible obstacles to rehabilitation, financial and family concerns, level of motivation, personal interests and avocations, and the necessary ingredients for a successful placement. Include injury restrictions, new job goal, why goal is appropriate, expected placement, salary and growth, injured worker’s responsibilities, and VR provider responsibilities. (Attach extra sheets if needed). EMPLOYEE’S RESPONSIBILITY: I will cooperate and make a good faith effort with all parties involved in my rehabilitation program. This includes the keeping of all appointments and adherence to reasonable requests. I understand that any aspect of my program can be amended with good reason. SIGNED ___________________________________________ DATE _________________ CERTIFIED VR PROVIDER RESPONSIBILITY: I will be responsible for timely delivery of the above-referenced services and agree to carry out my professional duties in the interest of the employee’s rehabilitation. I understand that this plan cannot be implemented without the approval of the Office of Education and Vocational Rehabilitation of the Department of Industrial Accidents. Should timelines or costs change in this program, I will notify the key parties and develop a program amendment. SIGNED ___________________________________________ DATE _________________ EMPLOYER/INSURER RESPONSIBILITY: I agree to pay for all reasonable and necessary VR services, and to monitor the costs and timeliness of services. SIGNED ___________________________________________ DATE _________________ OEVR RESPONSIBILITY: I will monitor the delivery of VR services to insure compliance with regulations and policy, ensure cost-effectiveness and quality of services. I agree to conduct team meetings to resolve any conflicts or issues amongst the key parties with respect to VR in a fair, objective and timely manner SIGNED ___________________________________________ DATE _________________ American LegalNet, Inc. www.USCourtForms.com