Return To Work Plan Direct Employment
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Return To Work Plan Direct Employment Form. This is a Oregon form and can be use in Vocational Rehabilitation Workers Comp.
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Tags: Return To Work Plan Direct Employment, 1083, Oregon Workers Comp, Vocational Rehabilitation
Submit to:
Department of Consumer & Business Services
Workers’ Compensation Division
350 Winter St. NE
P.O. Box 14480
Salem, Oregon 97309-0405
Return-to-Work Plan;
Direct Employment
Date:
Worker:
Counselor (name, phone):
WCD file no.:
VRO (name, city):
Insurer:
Claim no.:
DOI:
1. Vocational objective(s):
S.O.C/D.O.T. code(s):
2. Plan dates:
Expected weekly RTW wage:
3. Specific services required to meet objectives:
Start date:
Projected end date:
4. Responsibilities of worker and counselor unique to
this plan:
5. I understand my responsibilities under this plan and
have received a copy of the plan support and both sides of
this form. I understand that the Workers’ Compensation
Division may review the plan.
Worker
Date
Plan developer
Date
Cosigner
Date
Insurer
Date
Insurer phone:
For WCD use
6. Comments:
In conformance
with OAR 436-120
Consultant
Date
Consultant
Date
Consultant
Date
Consultant
Date
Not in conformance
Revised to conform
Optional
440-1083 (12/07/DCBS/WCD/WEB)
1083
American LegalNet, Inc.
www.FormsWorkflow.com
Responsibilities under Return-to-Work Plan
Worker will do the following:
• Maintain regular contact with counselor.
• Fully participate in the return-to-work plan services.
• Follow up on all job leads in a timely manner.
• Accept suitable employment if it is offered and notify counselor immediately.
• Promptly inform counselor of any problem that might affect participation.
• Meet any responsibilities agreed to in this plan.
Counselor will provide the following services in accordance with OAR 436-120:
• Provide instruction on job-search skills, as necessary.
• Provide job development, as necessary.
• Provide timely, accurate progress reports to the insurer.
• Meet any other responsibilities agreed to in this plan.
Insurer will provide the following services in accordance with OAR 436-120:
• Contact the Workers’ Compensation Division to schedule a conference if no plan is approved within 45 days of
determining the worker entitled to a direct employment plan.
• File plan with Workers’ Compensation Division.
• Meet any other responsibilities agreed to in this plan.
440-1083 (12/07/DCBS/WCD/WEB)
American LegalNet, Inc.
www.FormsWorkflow.com
