VR-37E3 Nebraska Workers' Compensation Court P.O. Box 98908 Lincoln, Nebraska 68509-8908 (402) 471-3606 (800) 599-5155 When completed, mail to above address or Fax to NEWCC VR Section at (402) 742-8311 or Email to WCC.VocRehabSM@nebraska.gov SUBMIT PLAN CLOSURE REPORT (See attached instructions) 1 Name of employee: 2 Name of certified VR counselor: 3 4 FORMAL TRAINING Certificate Diploma A A Degree BA/BS Degree Other: ______________________ Supportive Services GED Other: ____________________________ 6 NEW JOB NEW EMPLOYER Supportive Services GED ELL ABE OJT Other: ____________________________________ 5 Date of Injury: Date of MMI: AWW at date of injury: Plan projected wage or range: If plan not completed, date cancelled: Employment start date: N/A Plan start date: Plan end date: Plan goal: Plan completed: Yes No 7 8 9 10 11 12 13 14 Employment status at plan closure: employed unemployed 15 16 Employment consistent with plan goal: Yes No N/A N/A 17 Job title at plan closure: N/A 18 Hourly wage at plan closure: 19 Number of hours worked per week: N/A 20 Plan Closure Reason(s) (check all that apply): Plan Completed Returned to work Lump sum settlement or release of liability Discontinued participating Failure to make satisfactory progress Changed program/focus area Medically unable to participate Other (explanation required) _______________________ hours billed: ______ hourly rate: $________ total amount billed: $________ 21 Counselor Professional Fees: JP Specialist Professional Fees: hours billed: ______ hourly rate: $________ total amount billed: $________ Expenses: 22 total amount billed: $________ Date: CERTIFIED COUNSELOR SIGNATURE: (6/16) American LegalNet, Inc. www.FormsWorkFlow.com Vocational Rehabilitation Plan Closure Report Instructions and Descriptions This form is to be filed at the conclusion of each approved plan, regardless of whether the plan was successfully completed. This form shall be filed within five working days after the plan is ended (see instruction #8). 1) Name of employee: Full name of employee. 2) Name of certified VR counselor: Full name of counselor of record, agreed upon/appointed to VR case. 3) Formal training plan: Complete all applicable items in this section. Select "formal training" and indicate any supportive service(s) associated with the plan by placing a check mark in the appropriate box(s). 4) Job placement plan: Complete all applicable items in this section. Select "new job new employer" and indicate any supportive service(s) associated with the plan by placing a check mark in the appropriate box(s). 5) Date of injury: Date of injury as identified on the VR plan form. 6) Plan start date: Indicate date VR plan started, as identified on the VR plan form. 7) Date of MMI: Indicate date employee reached maximum medical improvement per physician or ordered by a Judge. 8) Plan end date: Indicate date VR plan ended. If the plan was successfully completed include the date the plan was completed. If the plan was not successfully completed include the date the plan was cancelled by the court. 9) AWW on date of injury: Indicate average weekly wage on employee's date of injury per agreement by the parties or ordered by a Judge. 10) Plan goal: Include the job family from the Occupational Information Network (O*NET) that corresponds to the career and/or job goal(s) as identified on the VR plan form. 11) Plan projected wage or range: Report the projected wage or range of projected wages. 12) Plan completed: Indicate whether the plan was completed or not with a check mark in the appropriate box. 13) If plan not completed, date cancelled: If the plan was not completed include the date of plan cancellation in the area provided. 14) Employment status at plan closure: Indicate whether the employee was employed or unemployed at plan closure with a check mark in the appropriate box. If employment status cannot be determined leave both boxes blank and attach a written explanation of the steps taken by the counselor to contact the employee and/or otherwise determine employment status. 15) Employment start date: Indicate employee's employment start date. Place a check mark in the N/A box if the employee is not employed at time of plan closure. 16) Employment consistent with plan goal: Indicate if the employee's employment is consistent with the job family identified in box 10 of the form. Place a check mark in the N/A box if the employee is not employed at time of plan closure. 17) Job title at plan closure: If employed, include the employee's job title at plan closure or a term that describes the position held. Place a check mark in the N/A box if the employee is not employed at time of plan closure. 18) Hourly wage at plan closure: Report the employee's hourly wage, if employed, at the closure of the plan. Place a check mark in the N/A box if the employee is not employed at time of plan closure. 19) Number of hours worked per week: Report the employee's hours worked per week. Place a check mark in the N/A box if the employee is not employed at time of case closure. 20) Plan closure reason(s): Select the reason the plan has been closed. Check all that apply. American LegalNet, Inc. www.FormsWorkFlow.com Plan completed � Approved plan was successfully completed. Return to work - Employee is now working. Lump Sum Settlement or Release of Liability � The parties have agreed to a lump sum settlement or a release of liability. Discontinued participating - Employee failed to continue participating in the plan. Failure to make satisfactory progress - Employee's obligation under the Court's rules regarding satisfactory academic progress of maintaining at least a 2.0 grade point average each term as outlined in the Nebraska Workers' Compensation Court Student Information and Instructions Form (VR44SI). Changed program/focus area - The plan must be cancelled and a new plan submitted to the court when the approved plan's program/focus area has been changed. Medically unable to participate � Employee's medical condition(s) precludes participation in VR services. Other- All other above cancellation reasons do not apply. Provide a thorough explanation for closure on this form or attachment. 21) Counselor/Job Placement Specialist billing: For professional fees, include total number of hours billed, hourly rate, and total dollar amount billed by VRC and, if applicable, JPS for professional services rendered. For expenses, include the total amount billed for travel, mileage,