Mail or fax completed copy to: Department of Labor and Industry Workers' Compensation Division PO Box 64221 St. Paul, MN 55164-0221 (651) 284-5030 or 1-800-342-5354 Fax: (651) 284-5731 R-3 Rehabilitation Plan Amendment Print in ink or type Enter dates in MM/DD/YYYY format RP0 1 DO NOT USE THIS SPACE 2. Date of injury 1. WID number or SSN 3. Date of first consultation in person or telephone meeting (#29 on R-2) 4. Employee name 5. Insurer/self-insurer/TPA 6. Insurer claim number 7. Employer name 13. Change of QRC 8. QRC name 9. QRC address City 10. QRC # 11. QRC firm # State ZIP code 12. QRC phone number Yes No 14. Withdrawal of QRC Yes No Previous QRC # New QRC # 15. Proposed amendment and rationale (attach separate sheet as necessary) 16. Employee comments (if any) 17. QRC is to complete all service areas to be provided during the period covered by this R-3 AN Service category Description Projected cost Projected completion date 01 - Medical Management 02 - On-Site Job Analysis 03 - Coordinate RTW/same ER 04 - Job Modification 05 - Functional Capacities Evaluation 06 - Transferrable Skills Analysis 07 - Work Evaluation 08 - Work Hardening/ Adjustment MN RP01 (8/15) American LegalNet, Inc. www.FormsWorkFlow.com Service category Description Projected cost Projected completion date 09 - Job Seeking Skills Training 10A - Job Development (See instructions to QRC) 10B - Job Placement (See instructions to QRC) 11 - Post Placement/Follow-up 12 - Technical/Academic Skills Improvement 13 - Vocational Counseling/Guidance 14 - Vocational Testing 15 - On-the-Job Training 16 - Labor Market Survey 17 - Explore Retraining/Formal Retraining 18 ­ Administrative 19 - Preparation/Attend conference/hearing 20 - Expenses/Other Plan costs to date 18. Costs 19. Plan duration from plan filing date (in weeks) Weeks to date + + Projected additional costs to completion = Projected additional weeks to completion = Estimated total cost Estimated total weeks 20. Is this form being filed in lieu of a Plan Progress Report form (Minn. Rules 5220.0450, subp. A)? Yes No (complete #21 to 23) 21b. Medical report date 21a. Is the employee released to return with without Yes, Yes, No to work? restrictions restrictions 22a. Current work 22b. If working, is this a temporary job? Not working Part time Full time Seasonal layoff status Yes No 23. Do barriers to successful completion of the rehabilitation plan exist? Yes No If yes: List the barriers and the measures to be taken to overcome the barriers on a separate sheet and attach the list to this form. American LegalNet, Inc. www.FormsWorkFlow.com Employee signature QRC signature Date Date Claim representative signature QRC intern supervisor signature Date Date To the parties: If you disagree with the plan, you have 15 days from receipt of the proposed plan to resolve the disagreement or object to the proposed plan. The objection must be filed with the department on a Rehabilitation Request form. Rehabilitation plan privacy and confidentiality 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 staff members 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. Rehabilitation form availability 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. Intent to commit fraud 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. Instructions to QRC R-3 Rehabilitation Plan Amendment Form information This form can be used in several ways and might be filed multiple times during the course of a rehabilitation plan. Service codes and descriptions: See Minn. Rules 5220.0100 for service code definitions. However, for service codes 10A and 10B the statutory definition of job development in Minn. Stat. § 176.102, subd. 5, amends the definitions in Minn. Rules 5220.0100, subps. 16 and 18, as provided below. Service code 10A: "Job development" means systematic contact with prospective employers resulting in opportunities for interviews and employment that might not otherwise have existed and includes identification of job leads and arranging for job interviews. Job development facilitates a prospective employer's consideration of a qualified employee for employment. See Minn. Stat. § 176.102, subd. 5(b), for the maximum number of hours and weeks of job development services for dates of injury on or after Oct. 1, 2013. Service code 10B: "Job placement" means activities that support a qualified employee's search for work including the preparation of a client to conduct an effective job search and communication of information about the labor market, programs or laws offering employment incentives and the qualified employee's physical limitations and capabilities as permitted by data privacy laws. To amend a rehabilitation plan: The QRC or other parties may propose amendments to the current rehabilitation plan for good cause, including: · · · · · physical limitations interfere with the plan; the employee is not participating effectively; there is a need to change the vocational goal; the projected cost or duration will be exceeded; or the employee feels ill-suited for the type of work for which rehabilitation is being provided. When using this form to amend a rehabilitation plan, answer items 1 through 20. For item 17, check only the services to be provided during this R-3 plan period. For "Description" of the service, identify the activities to be performed within the service category (for example, attend me