Vocational Rehabilitation Closure Report Instructions · Please print or type. · Make sure to enter four digits for the year in all date fields. · Follow the distribution on the bottom of the form. Injured worker name (Last) Claim number Total service cost Case resolution (check one) Date of rehab case closure Total living maintenance cost · Include narrative. · Note: Injured worker's name, claim number and date must be on each page of attached narrative and justification. (First) Total length of services (number of weeks) Total case management cost (M.I.) Return to work SJSE Return to work DJSE Return to work SJDE Return to work DJDE No return to work Injured worker received the services noted below during the rehabilitation referral. Work conditioning, number of weeks: Training, number of weeks: Active physical therapy, number of weeks: Non medical interruption, number of weeks: Medical Interruption, number of weeks: Vocational guidance, number of weeks: Vocational evaluation/screening: Job placement, number of weeks: Other services (explain): Transitional work, number of weeks: Job modifications cost : Instructions for narrative and justification for closure Narrative must include a brief summary of the above services, injured worker's level of participation, return-to-work (RTW) obstacles encountered and overcome injured worker's strengths for RTW. Justification for closure must include a summary of circumstances of closure and a RTW explanation. If RTW is consistent with physical restrictions and abilities? Please explain. If the injured worker did not RTW at the targeted job, explain the reason and any attempts made to increase his or her employability. Note: Injured worker's name, claim number and date must be on each page of attached narrative and justification. Job at time of injury RTW employer RTW employer address Managed Care Organization Case management company City Job injured worker returned to * Total weekly hours scheduled State Date of RTW * Current gross weekly rate of pay Nine-digit ZIP code Date of referral Date case assigned Vocational case manager signature Telephone number Date * Obtain this information from the injured worker unless authorized to contact the RTW employer. Distribution: BWC claim file, injured worker, injured worker representative, employer, employer representative BWC-2972 (Rev. 8/26/2009) PC RH-21 American LegalNet, Inc. www.FormsWorkFlow.com