Mail completed copy to: On the Job Training Plan Department of Labor and Industry PO Box 64221 St. Paul, MN 55164-0221 (651) 284-5030 or 1-800-342-5354 (DIAL-DLI) PRINT IN INK or TYPE Enter dates in MM/DD/YYYY format. J A 0 4 DO NOT USE THIS SPACE Private or confidential data you supply on this form will be used to process your workers’ compensation claim. The data will be used by department of labor and industry (department) staff who have authorized access to the data, and may be used for state investigations and statistics. You may refuse to supply the data, but if you refuse your claim may be delayed or denied, or the form may be returned to you. The data will be made part of the department’s file for your claim and may be supplied to: anyone who has access to the file or the data by authorization or court order; the employer and insurer for your claim; the office of administrative hearings; the workers’ compensation court of appeals; the departments of revenue and health; and the workers’ compensation reinsurance association. WID or SSN DATE OF INJURY EMPLOYEE NAME INSURER/SELF-INSURER/TPA INSURER CLAIM NUMBER OJT JOB TITLE OJT EMPLOYER NAME OJT BEGINNING DATE OJT EMPLOYER ADDRESS OJT ENDING DATE CITY STATE ZIP CODE OJT PLAN PROGRESS EVALUATION DATE(S) Does this OJT employer intend to hire the employee upon completion of the OJT? Yes No JOB DESCRIPTION (attach a job analysis, or describe the nature of the work, giving examples of duties) Job must be within the employee’s physical restrictions. ATTACH MEDICAL REPORT. List the skills the employee will acquire through this training: List supplies and tools needed during training (itemize costs): TOTAL COSTS WEEKLY WAGES AND WORKERS’ COMPENSATION BENEFITS Start of OJT End of OJT Weekly wages paid by OJT Employer Weekly workers’ compensation benefits paid by Insurer cc: Employee, Insurer, OJT Employer MN JA04 (9/08) (over) American LegalNet, Inc. www.FormsWorkFlow.com RATIONALE FOR OJT: see Minn. Rule 5220.0850, subp. 2(N) [NOTE: Justification is required for plans EXCEEDING 6 months: see Minn. Rule 5220.0850, subp. 3] ACCEPTED PLAN: If all parties are in agreement with (and have signed) this OJT Plan, submit it to the Department with the required attachments for approval or denial (see Minn. Rule 5220.0850, subp. 4). Employee Signature Print or type name Phone number Date Insurer Representative Signature Print or type name Phone number Date OJT Employer Signature Print or type name Phone number Date OJT Trainer Signature Print or type name Phone number Date QRC Signature Print or type name Phone number Date QRC Number INSTRUCTIONS TO QRC DISPUTED PLAN: To resolve a disputed OJT Plan, call the Department’s Benefit Management and Resolution Unit at (651) 284-5032, and/or file a Rehabilitation Request (see Minn. Rule 5220.0850, subp. 5). DO NOT SUBMIT A DISPUTED PLAN to the Department without attaching it to a Rehabilitation Request, unless a Rehabilitation Request has been filed or will be filed by another party. This material can be made available in different forms, such as large print, Braille or on a tape. To request, call (651) 284-5030 or 1-800-342-5354 (DIAL-DLI)/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. For Department Use Only Approved DLI Representative Signature Denied Print or type name Phone number Date Reason for denial: American LegalNet, Inc. www.FormsWorkFlow.com