Mail or fax to: MN Department of Labor and Industry Workers' Compensation Division PO Box 64221 St. Paul, MN 55164-0221 (651) 284-5032 or 1-800-342-5354 Fax: (651) 284-5731 1. WID or SSN Filed as required by Minn. Rules 5220.0110, subp. 7 D0 S1 Disability Status Report PRINT IN INK or TYPE ENTER DATES IN MM/DD/YYYY FORMAT DO NOT USE THIS SPACE 2. DATE OF INJURY 3. EMPLOYEE NAME 4. EMPLOYEE ADDRESS CITY STATE ZIP CODE 5. EMPLOYEE PHONE # 6. EMPLOYER 7. EMPLOYER CONTACT PERSON 8. PHONE # 9. INSURER/SELF-INSURER/TPA 12. TITLE OF JOB AT DATE OF INJURY 10. INSURER ADDRESS 13. AVERAGE WEEKLY WAGE AT DATE OF INJURY 14. JOB AT DATE OF INJURY FULL TIME PART TIME 16. IS THE EMPLOYEE CURRENTLY WORKING? CITY STATE ZIP CODE 15. NUMBER OF DAYS OF DISABILITY 11. INSURER CLAIM NUMBER YES NO 17. WILL THE DISABILITY LIKELY EXTEND BEYOND 13 WEEKS? (see instructions on back) YES NO 18. REASON FOR FILING THE DISABILITY STATUS REPORT: (Check A or B) Was a consultation requested? Insurer A. Employer NO YES If yes, consultation requested by: (date of request) Employee on The employee is being referred for a rehabilitation consultation. (Insurer must send a copy of this Disability Status Report, the First Report of Injury, and the treating physician's work ability report to the QRC before the rehabilitation consultation.) Name of QRC B. A waiver of the rehabilitation consultation is being requested. An offer of suitable gainful employment signed by the date-of-injury employer and the treating physician's work ability report are attached. (NOTE: A waiver will not be granted if a consultation has been requested pursuant to Minn. Stat. � 176.102, subd. 4(a).) Projected return to work date Name of insurer representative completing form Phone number Extension Date served on employee (over) MN DS01 (9/12) Send to: Workers' Compensation Division, Employee American LegalNet, Inc. www.FormsWorkFlow.com INSTRUCTIONS TO INSURER The Disability Status Report (DSR) is used to notify parties that you are either referring the injured worker for a rehabilitation consultation or requesting a waiver of the consultation. The DSR, with the treating physician's work ability report, must be mailed to the injured worker and filed with the Department of Labor and Industry: x x x x x Within 14 calendar days of knowledge that the employee's temporary total disability is likely to exceed 13 cumulative weeks; or Within 90 calendar days of the date of injury when the employee has not returned to work following a work injury; or Within 14 calendar days after receiving a request for a rehabilitation consultation, whichever is earlier; or Within 14 calendar days of expiration of an approved waiver of rehabilitation services. To Refer for a Rehabilitation Consultation: If you are referring the injured worker for a rehabilitation consultation, check Box 18A. Send a copy of the DSR form, the First Report of Injury and the treating physician's work ability report to the QRC prior to the consultation pursuant to Minn. Rule 5220.0130, subp. 3(A). Fill in the name of the QRC on the form and indicate which party requested the consultation. If the employee requested the consultation, fill in the date of the request. To Request a Waiver of a Rehabilitation Consultation: M.S. � 176.102, subd. 4 and Minn. Rules 5220.0110 and 5220.0120 provide that the commissioner may grant a waiver of a rehabilitation consultation to an otherwise qualified employee if there is documentation that the employee will return to suitable gainful employment with the date-of-injury employer within 90 calendar days after the request for waiver is filed. A waiver will be denied if no documentation is submitted showing that a suitable job offer within the treating doctor's restrictions has been made. A waiver will also be denied if a consultation has been requested. If you are requesting a waiver, check Box 18B and attach the following documentation: x Report of Work Ability or other medical report with the same information from the treating doctor which indicates that the employee will be released to return to work within 90 calendar days after the request for waiver is filed and specifying the employee's work restrictions in functional terms. Written offer of suitable gainful employment signed by the employer that is within the treating doctor's restrictions to which the employee will return within the timeframe indicated above. Include one of the following: x x If the employer is offering the employee his/her date-of-injury job, any modifications of the job to accommodate the employee's restrictions must be noted. If the written offer of suitable gainful employment (which does not include temporary, light-duty) is for a different job with the date-of-injury employer, the offer must include the job title, job environment, work tasks, weekly wage, physical, mental and educational demands of the job, and/or employer modifications of the job to accommodate the employee's restrictions. x INSTRUCTIONS TO EMPLOYEE If you have a question about this form or rehabilitation services, call the Workers' Compensation Division at 1-800-3425354 or 651-284-5032. This material can be made available in different forms, such as large print, Braille or audio. To request, call (651) 284-5032 or 1-800-342-5354 Voice or TDD (651) 297-4198. ANY PERSON WHO, WITH INTENT TO DEFRAUD, RECEIVES WORKERS' COMPENSATION BENEFITS TO WHICH THE PERSON IS NOT ENTITLED BY KNOWINGLY MISREPRESENTING, MISSTATING, OR FAILING TO DISCLOSE ANY MATERIAL FACT IS GUILTY OF THEFT AND SHALL BE SENTENCED PURSUANT TO SECTION 609.52, SUBDIVISION 3. 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