Mail or fax to: 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 Plan Progress Report Print in ink or type Enter dates in MM/DD/YYYY format P0 R1 DO NOT USE THIS SPACE 1. Date of this report 2. WID number or SSN 4. Employee name 5. Employee address City 7. Employer name 10. Insurer claim number 11. Insurer/self-insurer/TPA 12. Insurer address State ZIP code 6. Date of rehabilitation consultation: (#29 on R-2) 8. Employer contact person 15. QRC name 16. QRC firm 17.Address 9. Phone number 3. Date of injury City State ZIP code City State ZIP code 13. Claim representative 14. Phone number 18. QRC # 19. QRC firm # 20. Phone number 21. Is the employee released to return to work? 22. Current work status: 23. Is the plan still current? Not working Yes Plan costs to date 24. Costs 25. Plan duration from plan filing date (in weeks) Duration to date Yes, restrictions Full time with Yes, restrictions Seasonal layoff without Medical report date No If working, is this a temporary job? Yes No Part time No Other costs necessary to complete plan + = Expected additional duration to plan completion + Yes No = Estimated total cost Estimated total duration 26. Do barriers to successful completion of the rehabilitation plan exist? If yes, list these on a separate sheet along with the measures to be taken to overcome those barriers, and attach it to this form. QRC Signature Date QRC Intern Supervisor Signature Date This form is required to be filed 6 months after filing the R-2 (unless an R-3 is filed 15 days before or after 6 months have passed since the R-2 filing date). See Minnesota Rules 5220.0450, subp. 3 A. Send copies to the employee, insurer and attorney(s). Send to the date-of-injury employer if the goal of the rehabilitation plan is to return to work with that employer. This form and access to the electronic submission format is located at www.dli.mn.gov/WC/WcForms.asp. The form can be made available in different formats, such as large print, Braille or audio. To request, call (651) 284-5032 or 1-800-342-5354. 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 Minnesota Statutes § 609.52, subd. 3. MN PR01 (01/2014) American LegalNet, Inc. www.FormsWorkFlow.com