Mail completed copy to: Department of Labor and Industry P.O. Box 64221 St. Paul, MN 55164-0221 (651) 284-5030 or 1-800-342-5354 Retraining Plan Print in ink or type Enter dates in MM/DD/YYYY format. E0 P4 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 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. WID number or SSN Employee name Employer name Insurer/self-insurer/TPA Insurer claim number Date of injury Claim representative Telephone number Pre-injury job title Occupational goal(s) Certificate/degree program title School name Program length (weeks) Pre-injury average weekly wage Current compensation rate Anticipated average weekly wage (from Labor Market Survey) Program start date City Program completion date State ZIP code ITEMIZED COSTS: Tuition/lab/activity fees Books/tools Special/unique costs* Custodial day care Travel/parking Total retraining costs (excluding wage benefits) *Explain (for example, tutoring, board and lodging) Required attachments: Pursuant to Minnesota Rules 5220.0750, subp. 2(H), the following items must be attached. a. Course syllabus/class titles b. Physical requirements of the job for which the employee is being trained (on-site job analysis is preferred) c. Medical information that the training and the occupational goals are within the employee's restrictions d. Vocational evaluation test results that support course choice e. Recent Labor Market Survey MN EP04 (01/2014) (over) cc: Employee, insurer, attorneys American LegalNet, Inc. www.FormsWorkFlow.com Retraining rationale (see Minn. Rules 5220.0750, subp. 2(F): Accepted plan: If all parties are in agreement with (and have signed) this Retraining Plan form, submit it to the department with the required attachments for approval or denial (see Minn. Rules 5220.0750, subp. 5). Employee signature Insurer representative signature QRC signature QRC intern supervisor Print or type name Print or type name Print or type name Print or type name QRC # QRC # Telephone number Telephone number Telephone number Telephone number Date Date Date Date INSTRUCTIONS TO QRC Note: Retraining is limited to 156 weeks. Disputed pl an: To resolve a disputed Retraining Plan, call the Department of Labor and Industry's A lt er n a ti v e D is p ut e Resolution unit at (651) 284-5032 and/or file a Rehabilitation Request form (see Minn. Rules 5220.0950). Do not submit a disputed plan to the d e partment without attaching it to a Rehabilitation Request form, unless a Rehabilitation Request form has been filed or will be filed by another party. 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. Rehabilitation form availability This form 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. For department use only Approved DLI representative signature Reason for denial: Denied Print or type name Telephone number Date American LegalNet, Inc. www.FormsWorkFlow.com