Department of Labor and Industries SELF INSURANCE This form must be completed by a vocational Rehabilitation counselor who has received a referral from a self-insured employer. RETURN TO WORK PLAN TIME ENCUMBRANCE Original **** Counselor is responsible for sending a copy of this form to each vendor **** Date of this request Modification Claim number Vocational counselor or Intern VRC or Intern ID # Vocational counseling firm's name Phone number Injured worker's name Date of injury Address Firm Provider # & branch Home address Phone number City/State ZIP+4 City/State ZIP Type of Modification Plan Dates Requested Change in time frames Effective start date Change in goal Change start date to Change in training site Interrupt plan on Change in costs Restart plan on Continue time loss to LEP to start on Other (specify) LEP to end on End date, 1st 52 weeks Early plan termination Goal DOT # Method Training site Contact person Date signed Phone Signature, Assigned Vocational Counselor. X Company Phone No. Assigned Vocational Counselor Date Employer or Service Representative Not Approved Approved Date signed F207-172-000 rtw plan time encumbrance 5-05 Phone No. FAX No. Signature Signature American LegalNet, Inc. www.USCourtForms.com