Fill and Sign the Ca Work Compensation Form

Employer (name of firm)      (name of job)       You may contact       concerning this offer. Phone No.:       Date of offer:       Date job starts:       Claims Administrator:       Claim Number:       Name of employee:       Date offer received:       I accept this offer of Modified or Alternative work. I reject this offer of Modified or Alternative work and understand that I am not entitled to vocational rehabilitation services.             NOTICE OF OFFER OF MODIFIED OR ALTERNATIVE WORK THIS SECTION COMPLETED BY EMPLOYER OR CLAIMS ADMINISTRATOR: is offering you the position of a Attach a list of the duties required of the position. NOTICE TO EMPLOYEE You have 30 calendar days from receipt to accept or reject this offer of modified or alternative work. If you reject this job offer, you will not be entitled to rehabilitation services unless: Modified Work A. The proposed modification(s) to accommodate required work restrictions are inadequate. B. The modified job will not last 12 months. Alternative Work A. You cannot perform the essential functions of the job; or B. The job is not a regular position lasting at least 12 months; or C. Wages offered were less than 85% of the wages paid at the time of injury; or D. The job is beyond a reasonable commuting distance from residence at time of injury. THIS SECTION TO BE COMPLETED BY EMPLOYEE: Signature: Date : I feel I cannot accept this offer because: NOTICE TO THE PARTIES If the offer is not accepted or rejected within 30 days of the offer, the offer is deemed to be rejected by the employee. The employer or claims administrator must forward a completed copy of this agreement to the Rehabilitation Unit with a Case Initiation Document (DWC Form RU-101) and Notice of Termination (DWC Form RU-105) within 30 days of acceptance or rejection. If a dispute occurs regarding the above offer or agreement, either party may request the Rehabilitation Unit to resolve the dispute by filing a Request for Dispute Resolution (DWC Form RU-103) at the nearest office of the State of California, Division of Workers' Compensation, Rehabilitation Unit. Mandatory Format State of CaliforniaDWC Form RU-94 (3/99) Rehabilitation Unit California Division of Workers' Compensation Form RU-94 NOTICE OF OFFER OF MODIFIED OR ALTERNATIVE WORK Purpose: To document an offer of modified or alternative work by the employer at the time of injury. The form also documents the acceptance or rejection of modified or alternative work by the injured employee. The RU-94 is to be used only for injuries which occur on or after 1-1 -94. Submitted by: The claims administrator obtains the response of the injured worker and submits the form to the Rehabilitation Unit. When prepared: The form is prepared at the time of the offer of modified or alternative work by the employer or claims administrator. This form is not to be used to document a plan for modified or alternative work offered subsequent to advising the worker that modified or alternative work was not available. Where submitted: Initially to the injured worker within 30 days of the acceptance or rejection of the offer, then it is submitted to the Rehabilita- tion Unit. Form completion: The employer or claims administrator completes the information in the top box. The employee completes the section so marked. Accompanyina document: The RU-94 is submitted with a RU-105 Notice of Termination and a RU- 101 if no case exists. The submitted RU-94 must also include a list of duties required of the position and wages offered. Rehabilitation Unit action: The Rehabilitation Unit will not take action unless the employee objects by filing a RU-103, Request for Dispute Resolution to the Notice of Termination. Note: Once the offer of employment is made, the employee has 30 days from the date of the offer, to accept or reject the offer. If the offer is not accepted or rejected, it is assumed the offer is rejected. The employer has the option to file a RU-105 Notice of Termination or extend the 30 day period by mutual agreement.