COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : : Plaintiff(s) : : Index No. Calendar No. INDIVIDUAL WRITTEN REHABLITATION PLAN (IWRP) ORIG: ___ AMEND: ____ JUDICIAL SUBPOENA -against- EMPLOYEE NAME:_____________________________ EMPLOYER:______________________________________ : S.S.NO:________________________________________ OCCUPATION:____________________________________ D.O.I.:_________________________________________ EDUCATION LEVEL:______________________________ D.O.B.:________________________________________ CARRIER: _______________________________________ : A.W.W.:_______________________________________ DATE OF VR REFERRAL: _________________________ DISABILITY:____________________________________________________________________________________ Defendant(s) : ...................................................... MEDICAL JUSTIFICATION FOR THE VOCATIONAL GOALS WITH THE ATTACHED MEDICAL REPORT: LEVEL OF SERVICE: THE PEOPLE OF THE STATE OF NEW YORK TO VOCATIONAL GOAL WITH RATIONALE AND ESTIMATED WEEKLY EARNINGS: GREETINGS: DETAILED PLAN OF VOCATIONAL SERVICES INCLUDING THE NATURE AND EXTENT OF SERVICES AND THE PROJECTED DATES OF SERVICE:that all business and excuses being laid aside, you and each of you attend before WE COMMAND YOU, , the Honorable at the Court located at County of in room , on the day of , 20 , at o'clock in the noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply. EMPLOYEE AND REHABILITAITON PROVIDER RESPONSIBILITIES FOR THE IWRP: Witness, Honorable Court in County, , one of the Justices of the day of , 20 (Attorney must sign above and type name below) Attorney(s) for ____________________________________________ EMPLOYEE SIGNATURE DATE ____________________________________________ REHABILITATION PROVIDER DATE _________________________________________________ Office and P.O. Address EMPLOYER REPRESENTATIVE DATE _________________________________________________ LABOR DEPARTMENT No.: APPROVAL DATE Telephone Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com