Department of Labor and Industries 2nd 52 WEEK PERIOD This form must be completed by the Vocational Counselor assigned by either State Fund or Self Insurance. RETURN TO WORK PLAN TIME ENCUMBRANCE Original **** Counselor is responsible for sending a copy of this form to each vendor **** Date of this request Assigned Vocational Counselor VRC Phone number Address Firm Provider # & branch Home address City/State ZIP+4 Claim number VRC Provider ID # Vocational counseling firm's name Modification Type of Modification: Injured worker's name Date of injury Phone number City/State ZIP Plan Dates Requested Effective start date Change in time frames Change start date to Change in goal Interrupt plan on Change in training site Restart plan on Change in costs Continue time loss to LEP to start on Other (specify) LEP to end on End date, 2nd 52 weeks Early plan termination Goal Method DOT # Training site Contact person Phone L&I USE ONLY Company Phone No. Assigned Vocational Counselor Date FAX No. Signature For Dept Use Only Vocational Services Specialist Date Not Recommended Recommended Phone No. Signature Supervisor of Industrial Insurance Not Approved Approved Phone No. Signature Date F245-356-000 2nd 52 wk rtw plan time encumbrance 01-2008 Do not use for workers with training plans approved after 1-1-2008 INDEX: VPLAN American LegalNet, Inc. www.FormsWorkflow.com