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California Employee Statement of Declination of Vocational Rehabilitation Services

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Employee Statement of Declination of Vocational Rehabilitation Services

State of California - Division of Workers' Compensation - Form RU-107

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 along with a properly completed Notice of Termination of Vocational Rehabilitation Services (DWC Form RU-105). If a Rehabilitation Unit case does not exist, it must be accompanied by a Case Initiation Document (DWC Form RU-101).

Employee Name: 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 rehabilitation 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 determine 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 rehabilitation 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 . 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

Declaración del Empleado de Renuncia a los Servicios de Rehabilitación Vocacional

Estado de California - División de Compensación al Trabajador - Formulario DWC RU-107

INSTRUCCIONES:

Se debe utilizar este formulario cuando un empleado renuncia a la rehabilitación después de habérsele informado que por motivos médicos tiene derecho a ella. Debe ser firmado por el empleado y su representante, si lo tuviere, y presentado a la Unidad de Rehabilitación por el patrón junto con un formulario de Solicitud para Terminar los Servicios de Rehabilitación (Formulario DWC RU-105) debidamente llenado. Si el caso no tuviera un número de la Unidad de Rehabilitación, este formulario debe ir acompañado del formulario Documento de Iniciación de Casos (Formulario DWC RU-101).

Nombre del empleado: # de caso UR:

AVISO AL EMPLEADO

El propósito de este formulario es registrar oficialmente el hecho que usted desea terminar su derecho a recibir beneficios de rehabilitación. Si usted renuncia a los servicios de rehabilitación, el derecho que usted tiene a ellos finalizará una vez que la Unidad de Rehabilitación haya aprobado su decisión. Esto significa que su patrón ya no estará obligado a proporcionar servicios de rehabilitación en una fecha posterior, a menos que las reglas y reglamentos de la Junta de Apelaciones de Compensación al Trabajador estipulen lo contrario de acuerdo con la Sección 5410 del Código Laboral.

DESCRIPCIÓN DE LOS SERVICIOS DE REHABILITACIÓN VOCACIONAL

Si usted ha sufrido una lesión que se relaciona con su trabajo y le impide seguir desempeñando su trabajo anterior, usted tiene derecho a recibir servicios de rehabilitación. La cantidad de servicios que reciba dependerá de sus necesidades y de las destrezas que usted tenga.

Algunos planes de rehabilitación contemplan que su trabajo anterior se modifique, o que se le proporcione otro trabajo con el mismo patrón o un patrón nuevo. Otros planes incluyen capacitación para un nuevo tipo de trabajo. Su patrón paga todos los costos de su rehabilitación. Durante su rehabilitación, usted recibirá un subsidio de mantenimiento. Usted tiene derecho a que se le evalúe antes de que tenga que tomar una decisión para determinar qué alternativas de rehabilitación tiene. El derecho que usted tiene a la rehabilitación es un derecho adicional a los demás derechos que tiene de recibir beneficios de Compensación al Trabajador y no se pueden cancelar con un pago en efectivo. Si usted no está listo para participar en este momento en la rehabilitación, pero podría estarlo más tarde, es posible posponer su participación en la rehabilitación durante un tiempo.

Si desea mayor información al respecto, puede ponerse en contacto con la Unidad de Rehabilitación o de la Oficina de Determinación de Beneficios, sin costo alguno, o puede hablar con un abogado.

DECLARACIÓN DE RENUNCIA

Este formulario debe ser firmado por el empleado lastimado.

El empleado lastimado declara:

He leído esta declaración de Renuncia a los Servicios de Rehabilitación Vocacional.

He recibido el folleto Ayuda para Regresar a Trabajar.

Renuncio a recibir rehabilitación.

He conversado con un Representante Calificado de Rehabilitación (QRR).

Comprendo que al firmar este formulario estoy renunciando a un servicio al que tengo derecho.

FIRMA DEL EMPLEADO:

Fecha:

Firma del representante, si lo hubiere.

El representante declara:

He revisado este formulario con mi cliente y

Le he explicado las consecuencias de renunciar a los beneficios de rehabilitación vocacional.

FIRMA DEL REPRESENTANTE DEL EMPLEADO:

Fecha:

PARA USO EXCLUSIVO DE LA UNIDAD DE REHABILITACION

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 1/1/90, 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.

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What this California Employee Statement of Declination of Vocational Rehabilitation Services does

The California Employee Statement of Declination of Vocational Rehabilitation Services is a written record documenting an injured employee's informed decision to decline vocational rehabilitation or job-placement services offered through a workers' compensation claim. It captures identifying details, claim numbers, the services offered, the employee's explicit declination language and signature, and the date. Employers and claims administrators retain the completed form in the claim file to show the employee received the offer and knowingly declined services, which helps support accurate claim handling and protects both parties in later disputes.

Why a clear declination statement matters

A concise, signed declination documents informed refusal, reduces ambiguity in the claim record, and helps employers and insurers satisfy documentation obligations while preserving employee rights under California workers' compensation rules.

Why a clear declination statement matters

Who completes and relies on this declination statement

This form is used by employees, employers, claims adjusters, and vocational rehabilitation providers to record a formal decline of services.

  • Employees — to confirm voluntary declination after receiving an offer of vocational rehabilitation services.
  • Employers and HR — to document compliance with claim workflows and internal recordkeeping procedures.
  • Claims adjusters — to close or adjust vocational rehabilitation steps and update the claim status.

Keep a signed copy in the claim file and share it with the adjuster and HR according to company procedures.

Essential parts of a professional declination form

A complete California Employee Statement of Declination of Vocational Rehabilitation Services should be structured to show the offer, the employee response, and the supporting metadata necessary for the claim file and future audits.

Employee Details

Full legal name, date of birth, employee ID or claim number, contact information, and employer name so the declination is clearly attributable to one individual and one claim.

Claim and Offer Details

Date of the vocational services offer, name of the provider or vendor, description of services offered, and any scheduled appointments or assessments included in the offer.

Declination Statement

Clear, unambiguous language the employee uses to decline the offer; statement should confirm the employee understands the nature of the services and is declining voluntarily.

Signature Block

Employee signature, printed name, date signed, and signature method (wet ink, electronic signature, or witnessed) documented for evidentiary clarity.

Employer / Adjuster Acknowledgment

Signature, printed name and title of the person who presented the offer and date of offer delivery to prove the offer was made and documented.

Record Notes

Optional section for comments, witness names, reason for declination (if volunteered), and directions on where the signed form will be stored.

Data points and privacy controls to include

Employee Name: Full legal name
Claim Number: Employer or insurer claim ID
Declination Date: MM/DD/YYYY format
Signature Method: Wet or eSignature
HIPAA Consideration: PHI handling note
Retention Location: Claims file path

Step-by-step: filling out the declination form

Complete the form in order: identify claim details, record the offer, capture the declination text, obtain signature, and file in the claim record.

  • 01
    Identify claim: Enter employee and claim identifiers at the top of the form.
  • 02
    Record offer details: Note the provider name, service description, and date the offer was made.
  • 03
    Capture declination: Use explicit language stating the employee declines the offered services.
  • 04
    Sign and store: Obtain signature, date it, and save a copy to the claim file.

How to set up an online declination workflow

Configure an e-signature workflow to capture the declination reliably with audit trail, storage, and optional authentication steps.

Field Configuration
Document Upload PDF or DOCX upload, limit 10 MB
Signer Authentication Email link or SMS code; use stronger auth if required
Signature Order Employee signs first, employer or adjuster acknowledges second
Archive Location Save to secure claims repository with access controls

Where to send or file the completed declination

A clear routing plan helps maintain the integrity of the claim file and ensures all stakeholders have access to the signed declination.

  • Deliver to Adjuster: Email signed copy to the assigned claims adjuster for the claim file.
  • Provide to Employer: Retain an employer copy in HR or risk management records.
  • Attach to Claim: Upload signed form to the insurer's claim management system.
  • Employee Copy: Give the employee a dated copy for their records.

Technical and distribution options for electronic completion

Decide how the form will be distributed and signed electronically, and confirm platform compatibility with your security and audit needs.

  • File formats: PDF, DOCX supported for upload and signing
  • Integration options: Connectors to Salesforce, NetSuite, Google Workspace
  • Authentication: Email link, SMS code, or advanced verifier controls

Ensure the platform chosen produces a tamper-evident signed file and retains an audit trail; store signed copies in the claims system with appropriate access controls and retention settings.

Timing and retention expectations for the declination

Certain timelines and retention expectations apply; keeping dated records minimizes future disputes and supports regulatory compliance.

When to record:

Record the declination on the date the employee signs the form.

Employer retention:

Retain the document in the claim file for the active claim period.

Internal deadlines:

Adjusters should note declination promptly when updating the claim status.

Employee copy timing:

Provide the employee a copy at signing or within a single business day.

Audit readiness:

Ensure the record includes timestamps and signer authentication data for audits.

Key milestones in processing a declination

Track milestone events from offer through final claim record update to ensure complete documentation and timely resolution.

01

Offer Presented

Employer or vendor documents the offer and the date it was presented to the employee.

02

Employee Response

Employee signs the declination form or provides an alternative documented response.

03

Adjuster Update

Claims adjuster records declination and updates claim workflow status and notes.

04

File Closure

Signed declination is archived and retained per recordkeeping rules for future review.

Common errors to avoid when preparing the declination

  • Incomplete identification fields that prevent matching the form to the correct claim can delay processing and create disputes.
  • Vague declination wording such as 'I refuse' without date or context leads to ambiguity about what was offered.
  • Missing signature or unsigned electronic records without audit trail can render the declination non-evidentiary in later proceedings.
  • Failure to provide the employee a copy of the signed form undermines transparency and may invite challenges.

Risks and consequences of incorrect or missing declinations

Invalid Form: May be challenged
Claim Delay: Processing slowed
Benefit Impact: Possible disputes over services
Legal Challenge: Increases litigation risk
Privacy Exposure: Improper PHI handling
Record Gaps: Audit noncompliance risk

eSignature vendor comparison for signing and storing declination forms

Comparison of baseline pricing and capabilities for common eSignature providers. signNow is listed first per platform data available for cost and compliance features.

signNow DocuSign Adobe Sign PandaDoc HelloSign
Starting Price $8/user/mo $15/user/mo $14/user/mo $19/user/mo $15/user/mo
Free Trial 7-day free trial Varies by vendor Varies by vendor Varies by vendor Varies by vendor
Bulk Send Yes Yes Yes Yes No
Audit Trail Yes Yes Yes Yes Yes
HIPAA Compliant Yes Yes Yes No No

Real-world examples of online signature use in paperwork

Organizations use electronic signatures to capture consent or declination efficiently while keeping robust audit records for compliance.

Martin Properties — Tim Martin

Martin Properties uses online signing for property and HR forms to streamline execution.

  • The platform works on mobile and offline.
  • "I can process and execute all of these documents online with 100% compliance and built-in security. Whether on mobile or working offline, I can get forms back to their necessary parties efficiently."

Fertility Centers — John Butler

A healthcare practice digitized consent and declination paperwork to reduce turnaround time and storage errors.

  • Integration with records cut processing time.
  • "The airSlate SignNow team has been exceptional, responsive, the API has been great, and we're extremely happy that we chose airSlate SignNow as a company."

Frequently asked questions about declination forms and e-signing

Answers to common questions about validity, electronic signatures, recordkeeping, and what happens after an employee declines services.


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