Fill and Sign the Direct Accessmass Sport Ampamp Spine Physical Therapy Form

Full Service Evaluation Only YesNoDeferred (Explain) INITIAL EVALUATION SUMMARY Claims Administrator: Employee:Address:Claim #-DOI:City/State/Zip:Employer:Contact Name: Date of Initial Evaluation: Reason for Referral: Initial Meeting and Impressions: Vocationally Feasible? Summary:Recommendations:Plan of Action: Next Reporting Date: QRR (print name): Signature:Date:Telephone Number: Attachments:Copies Sent To: a) Data Sheet a)b)b)c)c)d)d)e)e)State of California DWC Form RU-120 (9/98) page I of 4 / / /// / /// / /// / /// / /// / /// / /// / /// / /// / /// / /// / // MaleFemaleYesNoYesNoMarriedSingleDivorcedWidowedSeparatedYesNoYesNoYesNo (Explain): YesNoYesNoYesNo All Days All Shifts M-F Only 8-5 Only Yes Year: / CertificateAA/ASBA/BS MILITARY SERVICE: Dates of Service: Branch: INITIAL EVALUATION DATA SHEET PERSONAL INFORMATION: Name: Social Security No.: DOB:Phone No.: CA Driver's License No.: Exp. Date: License Restrictions (Explain): Distance willing to travel to work (one way): Areas willing to drive: Reliable vehicle available for transportation (full-time): If no, what method of transportation will be used? Willing to relocate? Work Shifts: Describe issues which may interfere with employee's participation in services:SOCIO-FAMILY FINANCIAL HISTORY Marital status: Number of Dependents Living at Home: Ages:Child Support Payments? Amount: $ Child care required: Estimated amount per week: $ Able to financially support self throughout duration of services: Receiving VRMA? Amount per week:$ Receiving PD Supplement? Amount per week:$ Other sources of income (explain): EDUCATIONAL BACKGROUND High school graduate? Year:Name & Location of High School: If not HS graduate, GED? Post-HS Studies: Year:If no GED, Last grade completed: Area of Study: English Language: Other Language: SpeakYesNoSpeakYesNoReadYesNoLevel:ReadYesNoWriteYesNoLevel:WriteYesNoEmployee's List of Perceived Work Skills: Special Skills: State of California DWC Form RU-120 (9/98) page 2 of 4 / / / / / / / / YesNoYesYesYesYesNoNoNoNoYesNoYesNo Sitting: Can Can CanRightCannot Cannot CannotLeft //Driving: VOCATIONAL HISTORY Company & Location Dates Employed Job Title SalaryReason for Leaving From To MEDICAL FILE REVIEW Treating Physician: Phone:Address:Injury/Diagnosis:Permanent & Stationary: YesNoDate:Medical Restrictions/Limitations (specify medical report and date relied upon): Current Medications (specify medical report and date relied upon): Currently in Physical Therapy: Days/Times:Non-industrially Related Medical Conditions (explain): PRESENT PHYSICAL TOLERANCES (Subjective) minutesLifting:Reaching:Ready to Standing-minutes# of Pounds- Below shoulder Return to Work: minutesClimb steps: At shoulder Walking-minutesBending:Handling/FeelingVision Restriction: Dominant Hand: Pushing/PullingSupplemental Medical/Physical Information: State of California DWC Form RU-120 (9/98) page 3 of 4 AvailableNot Available Unknown/Not Requested EE Role QRR Role Carrier/ER Role Rehab Unit Role Help RTW Brochure Plan Hierarchy Caps/Limits on VR VRMADispute Resolution Process Effect of Delays Plan Definition Plan Parameters Termination Process Reinstatement Process Interruption Process Allowable Costs Nature/Extent of Added Costs Other (Explain) VOCATIONAL CONSIDERATIONS Preliminary Assessment of Transferable Skills: Client's Expressed Interest/Expectations of Vocational Rehabilitation: Observations (Comments on appearance, rapport, cooperation, attitude): VOCATIONAL FEASIBILITY FACTORS Can the employee reasonably benefit from the provision of vocational rehabilitation services? INVESTIGATION OF MODIFIED/ALTERNATIVE EMPLOYMENT Contact:Title:Date of Conduct: EXPLANATION OF VOCATIONAL REHABILITATION PROCESS (Check Box for all Issues Covered with Employee) State of California DWC Form RU-120 (9/98) page 4 of 4 Rehabilitation Unit California Division of Workers' Compensation Form RU-120 INITIAL EVALUATION SUMMARY Purpose: To document the findings and recommendations of the Qualified Rehabilitation Representative who conducts the initial evaluation. Per AR Section 10 1 32. 1, such assessment is to include an initial assessment of the worker's ability to benefit from VR services. Submitted by:Qualified Rehabilitation Representative (QRR). When submitted: The Rehabilitation Unit encourages an expeditious assessment of employee skills and vocational feasibility. The RU-120 should be submitted not later than 30 days from completion of the initial interview, unless otherwise agreed to. Where submitted: To the claims administrator with copies to all parties. If the QRR were functioning as an Independent Vocational Evaluator (IVE), the RU-120 would be filed directly with the Rehabilitation Unit with copies to all parties. Form completion: This form is to be completed by the QRR. The purpose of the form is to obtain comprehensive, yet concise, information which is critical for assessing vocational feasibility and developing an appropriate plan per the California Standards Govern- ing Timeliness and Quality of Vocational Rehabilitation Services. Information gathered for each section must fit within the section designated for that category and the typeface must be no smaller than I 0 point. The cost of additional or more detailed reports must be home by the party requesting them. Accompanying documents:None.Rehabilitation Unit action:None.Copy:All parties.