Fill and Sign the Ca Termination 497299505 Form

1. The employee declines and has signed the RU-107 or RU-107A. 2. The qualified employee completes a vocational rehabilitation plan. 3. The qualified employee unreasonably fails to complete a vocational rehabilitation plan. 4. The employee has not requested vocational rehabilitation within 90 days. 5. The employer offers and the employee accepts/rejects modified work lasting 12 months, even if the employee 6. The employer offers and the employee accepts/rejects alternative work meeting all of the conditions listed m 7. The employer offers and the employee accepts a job not meeting criteria of #5 or #6. (Attach RU-94) Yes No Yes No TO:      CLAIM #       Rehab Unit #       Social Security #                  If you have any questions about this notice, you may contact me at:             Total Amount VRMA paid: $       Modified Job Alternative Job Total Amount of PD Supplement: $       Phase I- $       Phase A- $             Phase II: $       Phase B- $             Phase III: $       Total costs of QRR services: $       Wages: $                         Total other costs of rehabilitation services: $             Amount withheld for Employee's Representative, if any: $                         NOTICE OF TERMINATION OF VOCATIONAL REHABILITATION SERVICES CLOSURE REASONS (Check one box which applies): voluntarily quits prior to the end of the 12 month period. (Attach RU-94) Labor Code Section 4644(a)(6). (Attach RU-94) NOTICE TO EMPLOYEE If you agree with the above, no further action is required on your part, and we will not be providing vocational rehabilitation services in the future. If you disagree with our determination that we have no further liability to provide vocational rehabilitation services, you or your representative must submit your written objections and the reasons for them to the Rehabili- tation Unit within 20 days of receipt of this notice. The form to use to make your objection is enclosed. Be sure to send a copy to me. The Rehabilitation Unit will then determine if you are to be given further services. Please send a copy of this notice with your objection to the Rehabilitation Unit, located at: (insert Rehabilitation Unit address) SUMMARY OF SERVICES PROVIDED Number of weeks of VRMA- Check if employee returned to work with previous employer, either: Amount Paid QRR for: DOI's on or after 1/1/94 VR Initiated on or after 1/11/98 Return to work other than above (The employer offers and the employee accepts job not meeting the criteria of modified or alternative work): VR Initiated before 1/1/98 Employee's New Job Title- Plan Type - Employed in plan objective: pe r QRR Name - Submitted by (Name)-Firm Name - City, State, Zip- Copies of this notice have been sent to: Phone Number- Date: Mandatory FormatState of CaliforniaDWC Form RU-105 (rev 9/98) Rehabilitation Unit California Division of Workers' Compensation Form RU-105 NOTICE OF TERMINATION OF VOCATIONAL REHABILITATION SERVICES Purpose: To notify the employee of the employer's termination of liability to provide rehabilitation services. It is not to be used for interruptions or non- feasibility. This notice is not to be used for injuries prior to 1990. Submitted by: Claims administrator to the injured employee and representative. When submitted: Within ten days of the circumstances set forth in Labor Code Section 4644(A). Where submitted: Original of the notice is sent to the employee and a copy to the applicable Rehabilitation Unit district office. Accompanvina documents: 1. RU-94 for date of injury on or after 1/1/94 where an offer of modified or alternative work has been accepted or rejected. 2. Agreed upon plans for represented injured workers whose date of injury is on or after 1/1/94. 3. All declination forms and notice of potential eligibility. 4. A copy of Proof of Service - 5. Case Initiation Document if no Rehabilitation Unit file number available. Rehabilitation Unit action: When the employee objects to the notice of termination, the Rehabilitation Unit will hold a conference or otherwise obtain the employee's reason for objection and issue its decision. Note: Copies of medical or vocational reports are not required to be submitted to the Rehabilitation Unit when filing a copy of the RU-105 on injuries occurring subsequent to 1/1/90. All RU-105 Notices must have a Proof of Service as required by AD 10131(a). For further information on Proof of Service, see Labor Code 8 Cal 10514.