Page 1 of 4 ( 4 /1 8 ) VR - 44 P.O. BOX 98908 LINCOLN, NE 68509 - 8908 Fax: (402) 742 - 8311 VOCATIONAL REHABILITATION PLAN ( Complete in a ccordance with the i nstructions on p age 4 . ) 1. EMPLOYEE INFORMATI ON 2. COUNSELOR INFORMATION Name: Address: City: State: Zip: Phone:Emai l: Employer: Job Title: DOT# AWW (Agreed To) : Attorney? No Yes Name : Phone:Fax:Email: United States Citizenship Attestation form must be submitted prior to plan approval. Name: Company Name: Address: City: State: Zip: Phone: Ext.: Cell Phone: Fax: E - mail: 3. INSURER INFORMATION 4. MEDICAL ( INJURY RELATED ) INFORMATION Company: Ad dress: City: State: Zip: Claim #: Claim Rep: Phone: Ext. Fax: E - mail: Attorney? No Yes Name : Phone: Fax: Email: Date of Injury: Diagnosis: Date of MMI : Physician : Per manen t Restrictions (describe ) : Physician : ( If there are multiple physician opinions with differing permanent restrictions, state whether the restrictions used are agreed to by the parties or determined by a judge. See plan instructions.) 5. PRIORITY / SUPP ORTIVE SERVICES REQUIREMENTS (Se e plan instructions for minimum requirements . ) A. NEW JOB NEW EMPLOYER Supportive Services GED ELL ABE OJT Other: a. PLAN STARTS: ENDS: MM/DD/YY MM/DD/ YY b . JOB GOAL (S) (with DOT code) : c . PROJECTED WAGE or RANGE: $ Source(s) of wage data: B. FORMAL TRAINING Certificate Diploma A A Degree BA/BS Degree Other: Supportive Services: GED Other: a. PLAN STARTS: ENDS: MM/DD/YY MM/DD/YY b. CAREER GOAL (Program & Focus Area): c. JOB GOAL ( S) (with DOT code) : d. PROJECTED WAGE or RANGE : $ Source(s) of wage data: American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 4 ( 4 /1 8 ) 6 . BI LLING INFORMATION : Complete all applicable items in the section, identifying all costs expected. It is under stoo d that costs for t uition & fees are estimated and subject to revision . A. TUITION & FEES : $ Authorize to: Addres s: City: State: ZIP: It is understood that r equired book costs , includ ing sales tax, are e stimated and subject to revision . B. REQUIRED BOOKS : $ Authorize to: Address: City: State: ZIP: General supplies (e.g., USB flash - drive, pens, pencils, notebooks) $30 .00 per term or s emester , in addition to the $30.00, include sales tax . C. GENERAL SUPPLIES : $ Authorize to: Address: City: State: ZIP: Required S upplies must be supported by documentation . An itemized list must be atta ched and prior approval must be obtained prior to purchase of these supplies. Include sales tax if applicable. D. REQUIRED SUPPLIES : $ Authorize to: Address: City: State: ZIP: Special Fe Include sales tax if applicable. Prior approval must be obtained. E. SPECIAL FEES : $ Authorize to: Address: City: State: ZIP: Any tutoring s erv ices require prior approval. Documentation of the need for tutoring may be requested. F. TUTOR INFORMATION & FEES : Hourly R ate: $ x Hours Per Week: x Number of Weeks: = Total : $ Authorize to: Telephone: Address: City: State: ZIP: 8. 7. TRANSPORTATION, BOARD , AND LODGING INFORMATION ( Check only applicabl e items in this section . See plan from instructions regarding reimbursement.) Job Placement Mileage Formal Training Mileage *Note amount of daily mileage to and from to training facility or institution - Supportive Service s Mileage Room and Board on - campus Room and Board off - campus where campus dorms are available Room and Board off - campus where campus dorms are not available American LegalNet, Inc. www.FormsWorkFlow.com Page 3 of 4 ( 4 /1 8 ) 8 . PLAN JUSTIFICATION ATTACH THE PLAN JUSTIFICATION TO THIS FORM PLAN JUSTIFICATION SHALL INCLUDE BUT IS NOT LIMITED TO THE FOLLOWING SECTIONS LABELED ACCORDINGLY AND PRESENTED IN THE ORDER SHOWN : Section A: Back ground I nformation Section D: Career/Job Goal Selection Section B: Vocational Assessment and Testing Section E: Labor Market Information Section C : Priority Selection SIGNATURES AND CERTIFICATIONS (Read carefully before signing) Vocational Rehabilitation Counselor : I hereby certify that: (1) this plan is reasonably necessary to restore the injured employee to suitable employment and that all lower priorities as listed in section 48 - RIWKH1HEUDVND:RUNHUV�&RPSHQVDWLRQ$FWDUH unlikely to result in suitabl e employment for the injured employee ; and (2) I have advised the injured employee that he or she may be responsible for any expenses incurred in carrying out this plan (a) without receiving approval of the plan by a vocational re habilitation specialist of WKHFRPSHQVDWLRQFRXUWDQGDFFHSWDQFHRIWKHSODQE\WKHHPSOR\HURUWKHHPSOR\HU�VZRUNHUV�FRPSHQVDWLRQLQVXUHURU risk management pool, or (b) without receiving approval of the plan by a judge of the compensation court. Employee : I hereby certify that: (1) I have reviewed this plan and the justification attached and I agree with the goal(s) of the pla n and t he means to attain the goal(s); ( 2) I will make a good faith effort to successfully comple te this plan within the specified time frame and I understand that failure to participate or make satisfactory progress may result in cancellation of or termination of fu nding for the plan; and (3) I have been advised by my counselor that I may be responsi ble for any expenses incurred in carrying out this plan (a) without receiving approval of the plan by a vocational rehabilitation specialist of the compensation court and acceptance of the plan by WKHHPSOR\HURUWKHHPSOR\HU�VZRUNHUV�FRPSHQVDWLRQLQVXUH r or risk management pool, or (b) without receiving approval of the plan by a judge of the compensation court. If the projected wage after rehabilitatio n is significantly less than my time - of - injury wage, I further certify that my counselor has discussed this with me and I understand and voluntarily accept the difference. (PSOR\HH�V6LJQDWXUH Date Employer/Insurer /Risk Management Pool : I hereby certify that the ? Insurer , ? Self - Insured Employer , ? Risk M anagement P ool accepts this plan and agrees to pay to the employee weekly compensation benefits for temporary disability while he or she is engaged in this plan. (PSOR\HU,QVXUHU5LVN0DQDJHPHQW3RRO�V6LJQDWXUH Date :RUNHUV�&RPSHQVDWLRQ&RXUW Vocational Rehabilitation Specialist : I certify that I have evaluated this plan in accordance w ith section 48 - RIWKH1HEUDVND:RUNHUV�&RPSHQVDWLRQ$FW and that t his vocational rehabilitation plan is hereby ? APPROVED ? DENIED 9RFDWLRQDO5HKDELOLWDWLRQ6SHFLDOLVW�V6LJQDWXUH Date &RXQVHORU�V6LJQDWXUH Date Page 4 of 4 ( 4 /1 8 ) INSTRUCTIONS FOR COMPLETING THE VOCATIONAL REHABILITATION PLAN 1. EMPLOYEE INFORMATIO N: Complete all applicable items in this section. DOT code is required IRUHPSOR\HH�VWLPH - of - injury occupation or an explanation must be provided in the Plan Justification section . The a verage weekly wage including overtime must be agreed to by all partie s or an explanation must be provided in the Plan Justification section . A United States Citizenship Attestation form must be submitte d prior to plan approval . Counselors are encouraged to submit the USCA form prior to plan submission to avoid delays. This form can be found at http://www.wcc.ne.gov . 2. COUNSELOR INFORMATION: Complete all applicable items in this section 3. INSURER INFORMATION : Complete all items in this section. If the employer is self - insured or a m ember of a risk management pool enter the name of the employer or pool. 4. MEDICAL INFORMATION : Complete all applicable items in this section. Date of MMI and permanent, injury - related restrictions are required and must be authored or endorsed by a physician. Do not rely on employee self - reported limitations. If there are multiple physician opinions with differing permanent restrictions, the permanent restrictions used must be agreed upon by the parties or determined by a Judge. Any FCE results must be endors ed by a physician. 5. PRIORITY/ SUPPORTIVE SERVICES : Complete all applicable items in this section. Select and check only one priority, either (A) New Job New Employer or (B) Fo rmal Training. A job goal or goals is required for either type of priority. If m ultiple job goals are proposed, list each job goal with DOT code, and explain in the pl an justification. Report t