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; Training Date: Worker: Counselor (name, phone): WCD file no.: VRO (name, city): Insurer: Claim no.: DOI: 1. Vocational objective(s): 2. Training kind(s): S.O.C./D.O.T. code(s): Start date: Expected weekly RTW wage: Projected end date: Training facility/employer: Attach copy of OJT contract, if applicable. 3. Other services: 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. My signature authorizes the training facility to release grades to my counselor and insurer. 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 440-1081 (12/07/DCBS/WCD/WEB) 1081 American LegalNet, Inc. www.FormsWorkflow.com Responsibilities under Return-to-Work Plan Worker will do the following: • Maintain regular contact with counselor. • Notify counselor if problems develop and continue attending training during attempts to resolve the issue. • Advise counselor immediately if anything threatens to interfere with successful completion of program. • Advise counselor by the close of the next workday if he/she stops attending training for any reason. • Maintain a 2.0 grade point average each grading period in formal training. • Complete the courses outlined in the curriculum by the plan end date. • Consult with counselor before adding or dropping courses. • Give a written training report to counselor by the fifth of each month. • Give counselor a copy of each grade or progress report within 10 days of receipt. • Meet any other responsibilities agreed to in this plan. Counselor will provide the following services in accordance with OAR 436-120: • Contact the worker on a regular basis, as necessary. • Contact the worker’s trainers and training site counselors, as necessary, to ensure that the worker’s participation and progress meet the requirements of the rules and are satisfactory to achieve the return-to-work objective(s). • Report potential problems in the training program to the insurer immediately, including additional needs of the worker. • Advise the insurer within 24 hours of learning of any circumstance(s) indicating a probable or actual interruption in the worker’s entitlement to time-loss benefits. • Provide job-search skills and job development as necessary. • Meet any other responsibilities agreed to in this plan. Insurer will provide the following services in accordance with OAR 436-120: • Insurer must contact the Workers’ Compensation Division to schedule a conference if no plan is approved within 90 days of determining the worker entitled to a training plan. • File plan with Workers’ Compensation Division. • Provide four months of job development following completion of training, if necessary. • Provide a minimum of 60 days of return-to-work follow up. • Meet any other responsibilities agreed to in this plan. Important information to the worker about time-loss benefits • Time-loss benefits will continue between the training start and end dates entered in Item 2 (front side). • Failure to follow the training plan will most likely result in the end of training and time-loss benefits. • When you complete this training and are medically stationary, the Workers’ Compensation Division or your insurer will determine your benefits. 440-1081 (12/07/DCBS/WCD/WEB) American LegalNet, Inc. www.FormsWorkflow.com