Fill and Sign the California Employee 497299506 Form

                                   State of CaliforniaDivision of Workers' Compensation EMPLOYEE STATEMENT OF DECLINATION OF VOCATIONAL REHABILITATION SERVICES INSTRUCTIONS: This form is to be used when the employee declines rehabilitation following notification of medical eligibility. It must be signed by the employee and his/her representative, if any, and submitted by the employer to the Rehabilitation Unit alongwith a properly completed Notice of Termination of Vocational Rehabilitation Services (DWC Form RU-105). If a RehabilitationUnit case does not exist, it must be accompanied by a Case Initiation Document (DWC Form RU-101). Employee Name: Last Firs t M.I . RU Case #- NOTICE TO EMPLOYEE The purpose of this form is to formally record your desire to end your right to rehabilitation benefits. If you decline rehabilitation services, your right for rehabilitation services will end upon the approval of the Rehabilitation Unit. This means your employer will not be required to provide rehabilitation services to you at a later date, unless otherwise determined pursuant to the Rules and Regulations of the Workers' Compensation Appeals Board in accordance with Labor Code Section 5410. DESCRIPTION OF VOCATIONAL REHABILITATION SERVICES If you had a work-related injury which prevents you from doing your former job, you are entitled to receive rehabilita- tion services. The amount of services you receive will depend on your needs and abilities. Some rehabilitation plans call for your former job to be modified, or for a different job with your same employer or a new employer. Other plans involve training for a new type of work. All of the rehabilitation costs are paid by your employer. During rehabilitation, you will receive a maintenance allowance. You have a right to an evaluation to deter- mine the vocational options available to you prior to making a decision. Your right to rehabilitation is separate from your other workers' compensation benefits and cannot under the Labor Code be terminated by a cash payment to you. If you are not ready to participate now in rehabilitation, but might be later, it is possible to delay your participation in rehabilita- tion for a period of time. If you want more information, you may contact the Rehabilitation Unit or the Office of Benefit Determination, at no charge, or contact an attorney.STATEMENT OF DECLINATION This form must be signed by the injured employee. The injured employee states: I have read this Statement of Declination of Vocational Rehabilitation Services. I have received the pamphlet Help in Returning to Work. I decline rehabilitation. I have met with a QRR.I understand by signing this form I am giving up a service to which I may be entitled. EMPLOYEE'S SIGNATURE- Date : Representative's signature, if any. The representative states: I have reviewed this form with my client and I have explained the effects of declining vocational rehabilitation benefits. EMPLOYEE'S REPRESENTATIVE'S SIGNATURE: Date : REHABILITATION UNIT USE ONLY State of CaliforniaDWC Form RU-107 (12/90)                        FIRMA DEL EMPLEADO:             FIRMA DEL REPRESENTANTE DEL EMPLEADO:             Nombre del empleado: Apellido Primer nombre Inicial # de caso UR: Fecha- Fecha- PARA USO EXCLUSIVO DE LA UNIDAD DE REHABILITAC1ON Estado de CaliforniaFormulario DWC RU-107 (12/90) Rehabilitation Unit California Division of Workers' Compensation Form RU-107 EMPLOYEE STATEMENT OF DECLINATION OF VOCATIONAL REHABILITATION SERVICES Purpose: To record the employee's declination of rehabilitation services for injuries on or after I/1/90, and until 12/31/93. Submitted by: Claims administrator. When submitted: When the employee chooses to decline vocational rehabilitation services. Where submitted: To the applicable Rehabilitation Unit district office. Form completion: Identifying data completed by claims administrator; signature of employee and attorney if represented. Accompanying documents: Notice of Termination of Vocational Rehabilitation Services Form RU-105. Notice of Potential Eligibility. Verification of the 90 day explanation of rights by a QRR. Case Initiation Document Form RU-101 if you do not know the Rehabilitation Unit case number. Response to RU-103: The other parties shall have twenty (20) days to respond by forwarding their position, with supporting information, to the applicable Rehabilitation Unit district office with copies to all parties. Rehabilitation Unit action: If the employee objects to the employer's Notice of Termination, the Rehabilitation Unit shall, within 30 days, schedule a conference or otherwise obtain the employee's reason for objection together with substantiating evidence and issue its decision. Copy: . All parties.