Mail or fax to: Department of Labor and Industry Worker's Compensation Division PO Box 64221 St. Paul, MN 55164-0221 (651) 284-5032 or 1-800-342-5354 Fax: (651) 284-5731 R-8 Notice of Rehabilitation Plan Closure Print in ink or type Enter date in MM/DD/YYYY format N0 R1 DO NOT USE THIS SPACE 1. Date of first consultation in person or telephone meeting (#29 on R-2) 2. WID number or SSN 3. Date of injury 7. Insurer claim number 4. Employee name 8. Date of injury employer 5. Employee address 9. QRC name City State ZIP code 10. QRC # 11. QRC firm # 12. QRC phone number 6. Insurer/self-insurer/TPA 13. Name of last placement vendor 14. Vendor # 15. Employment status at plan closure (check one) a. Employee RTW with DOI employer b. Employee RTW with different employer c. Released without physical limitations/effects of work injury and is unemployed (Skip to item 21) d. Employee not employed ­ Other (Skip to item 21) Complete items 16 to 20 if employee returned to work 16. Name of employer at plan closure 21. Reason for rehabilitation plan closure (check one) a. Plan completed (employee returned to suitable gainful employment) b. Award on stipulation/mediation c. Commissioner or compensation judge d. Employee and insurer have agreed to close the plan without a stipulation, mediation or order e. Unable to locate employee f. Death of employee g. QRC withdrawal 22. Did employee have an attorney? Yes No 23. If plan suspended by R-3 or order, indicate the number of weeks suspended 24. Training services (check all that apply) Retraining plan submitted ­ DLI/OAH did not approve Retraining plan submitted, award on stipulation/mediation Retraining commenced or completed Skills enhancement (such as short-term classes) On-the-job training commenced or completed 17. Job title at plan closure 18. Gross AWW at plan closure 19. RTW date 20a. Return to work job Same job 20b. Occupational demands Sed. Light Med Heavy Very heavy Modified job Different job 25. Total number of previous assigned QRCs involved in this rehabilitation plan: _______________ 26. Costs by service area and rehabilitation provider Prior placement firm costs 00 - Rehabilitation Consultation 01 - Medical Management N/A N/A Current placement firm costs N/A N/A Prior QRC firm costs Current QRC firm costs 11/6/13 American LegalNet, Inc. www.FormsWorkFlow.com Prior placement firm costs 02 - On-Site Job Analysis 03 - Coordination of RTW/Same Employer 04 - Job Modification 05 - Functional Capacities Evaluation 06 - Transferable Skills Analysis 07 - Work Evaluation 08 - Work Hardening/Adjustment 09 - Job Seeking Skills Training 10A - Job Development (See instructions to QRC) 10B - Job Placement (See instructions to QRC) 11 - Post Placement Activity/Follow-up 12 - Technical/Academic Skills Improvement 13 - Vocational Counseling/Guidance 14 - Vocational Testing 15 - On-the-Job Training 16 - Labor Market Survey 17 - Retraining 18 - Administrative 19 - Preparation/Attendance Legal Proceeding 20 - Expenses/Other Total costs of each column N/A N/A N/A N/A N/A N/A N/A Current placement firm costs Prior QRC firm costs Current QRC firm costs N/A N/A N/A N/A N/A N/A N/A Sum of column totals above By signing and dating this form, I certify copies of this form and attachments are being sent to the employee, insurer, any attorney(s), the Department of Labor and Industry and, if required, to the department's Vocational Rehabilitation unit (VRU). QRC signature Date QRC intern supervisor signature Date Employee If you have questions about the closure of this rehabilitation plan, call the Department of Labor and Industry at (651) 284-5032 or 1-800342-5354. Rehabilitation form availability This form is located at www.dli.mn.gov/WC/Wcforms.asp and 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. American LegalNet, Inc. www.FormsWorkFlow.com R-8 Notice of Rehabilitation Plan Closure Form Information Purpose: The Notice of Rehabilitation Plan Closure (R-8) form and the summary report document the closure of the plan. The R-8 is used to document the reason the plan is being closed or suspended, the employee's employment status at plan closure and the cost of all rehabilitation services that were provided under the plan. The narrative summary report describes the services that were provided from the beginning to the end of the plan. Both of these documents must be filed within 30 calendar-days of notice of any of the events listed in Minnesota Rules 5220.0510, subp. 7, or when the QRC withdraws under Minn. Rules 5220.0510, subp. 7a. Item 15: Employment status at plan closure ­ Check box c only if the employee is unemployed and has been released to return to any job, without any physical limitations/effects of work injury. Identify the documents (such as Work Ability form, etc.) that provide the basis for this selection within the R-8 summary report, then skip to item 21. Item 20a: Return to work ­ enter information about the job where the employee returned to work. Item 20b: Occupational demands ­ for DOT physical demands and strength rating description, see the R-2 Rehabilitation Plan form information sheet. Item 21: Reason for rehabilitation plan closure ­ a. the employee has been steadily working at suitable gainful employment for 30 days or more, or the time period provided for in the plan; b. the employee's rehabilitation benefits have been closed out by an award on stipulation or award on mediation; c. the commissioner or a compensation judge has ordered that the rehabilitation plan be closed and there has been no timely appeal of that order; d. the employee and insurer have agreed to close the rehabilitation plan; e. the QRC has been unable to locate the employee following a good faith effort to do so; f. the employee has died; or g. the QRC decides to withdraw after the insurer has provided written notice to the employee, the employee's attorney, the commissioner and the QRC that the insurer is denying further liability for the injury for which rehabilitation services are being provided. (For item 21g, the QRC must file the R-8 and attach a copy of the insurer's notice of denial, copying appropriate parties, including a separate copy to the department's Vocational Rehabilitation unit (VRU).) NOTE: Item 21g does not apply if a claim petition, objection to discontinuance, request for an administrative conference or other document initiating litigation has been filed for t