Fill and Sign the Ca Benefits Workers Compensation Form

                                               the qualified injured worker completed a vocational rehabilitation plan. the employee is not a qualified injured worker or the employee failed to cooperate in the provision of vocational the qualified injured worker unreasonably failed to complete an approved vocational rehabilitation plan. the employee declined, on the prescribed form, to accept the provision of vocational rehabilitation services. the employee failed to request timely reinstatement of vocational rehabilitation services. none of the above reasons apply and all necessary and reasonable vocational rehabilitation services have been provided.                   Date Rehab Services Completed:       Date-             Wages: $             1. The employee has been paid $       in temporary disability indemnity benefits at the rate of $       beginning       and ending       for the injury occurring on       Job Analysis Labor Market Survey Placement Services: Number of Weeks- Vocational Evaluation Vocational Testing Situational Assessments Counseling Financial Analysis Training: Number of Weeks-             Other (Specify)-                                                                         State of CaliforniaDivision of Workers' Compensation REQUEST FOR CONCLUSION OF REHABILITATION BENEFITS INSTRUCTIONS: This form must be used by the employer/insurer to re- quest the Rehabilitation Unit to determine when vocational rehabilitation ben-efits are concluded. This form is required on all cases in which vocationalrehabilitation benefits commenced. This request must be sent to the appli-cable Unit office. if a Rehabilitation Unit case number has not been assigned,attach a completed Case Initiation Document RU-101. This form should notbe used for interruptions of benefits. REHABILITATION UNIT USE ONLY EMPLOYEE NAME: (FIRST) (MIDDLE) (LAST) RU CASE #- EMPLOYEE ADDRESS: REHABILITATION UNIT ADDRESS: CITY, STATE, ZIP: CITY, STATE, ZIP: The Employer/Insurer requests Rehabilitation Unit approval of conclusion of vocational rehabilitation services because: rehabilitation services to determine the employee's eligibility as a qualified injured worker. The basis for this request is substantiated in the attached reports and is summarized as follows: NOTICE TO EMPLOYEE If you object to this request, you (or your attorney, if you are represented) must submit your written objections and the reasons for them to the Rehabilitation Unit within 20 days of the date of this request. The objection should be made on the Request for Dispute Resolution Form RU-103 and a copy must be sent to the employer/insurer. Within specified time limits and subject to certain criteria, you may request reinstatement of vocational rehabilitation benefits. Requests must be in writing, accompanied by supporting facts and submitted to the Rehabilitation Unit within one year of either a finding of permanent disability or approval of a compromise and release by the Workers' Compensa- tion Appeals Board, or within 5 years from the date of your injury. The Rehabilitation Unit will determine if the voca- tional rehabilitation services previously provided were sufficient or if you are entitled to additional services. SUMMARY OF VOCATIONAL REHABILITATION BENEFITS PROVIDED Date Rehab Services Commenced- Rehab Plan Type- Rehab Plan Goal- Return to Work: YES NO Employee's New Job Title- pe r per week, 2. Vocational rehabilitation services provided to the employee include: (check where applicable) COPIES OF THIS NOTICE HAVE BEEN SENT TO: SUBMITTED BY (Name): SIGNATURE: ADDRESS: CITY, STATE, ZIP: PHONE NUMBER: DATE: State of CaliforniaDWC Form RB-105 (pre 1/1/90) Rehabilitation Unit California Division of Workers' Compensation Form RB-105 REQUEST FOR CONCLUSION OF REHABILITATION BENEFITS Purpose: To request the Rehabilitation Unit's approval of conclusion of rehabilitation services for injuries before 1/1/90. For injuries on or after 1/1/90, use the Notice of Termination of Vocational Rehabilitation Services Form RU-105. Submitted by: Claims administrator. When submitted: Within ten (10) days of the circumstances as described on the form. Where submitted: To the applicable Rehabilitation Unit district office. Form completion: Please note this form will be returned or the request denied if • No rehabilitation case number has been assigned nor was the RU-101 Case Initiation Document attached. • The box was not checked for the reason of the request. • The request lacks substantiation as required. • Copies have not been sent to the employee and his/her representative, if represented. • The copy of service section is incomplete. Accompanying documents: Relevant medical and vocational reports. Rehabilitation Unit action: When the employee objects to the RB-105, the Rehabilitation Unit will hold a conference or otherwise obtain the reason for objection and issue its decision. If the employee objects, a RU-103 Request for Dispute Resolution must be filed. Check the box ''the requesting party objects to the request for termination or conclusion of vocational rehabilitation benefits'' and provide the reasons for the objection. Copy: All parties.