Fill and Sign the Oregon Return to Work Form

Submit to: Department of Consumer & Business Services Workers’ Compensation Division 350 Winter St. NE P.O. Box 14480 Salem, Oregon 97309-0405 Training Plan Date:       Worker:       Counselor (name, phone):       WCD file no.:       Vocational rehabilitation organization (name, city):       Insurer:       Claim no.:       Date of injury:       1. Vocational objectives: Standard Occupational Classification/Dictionary of Occupational Titles codes: Expected weekly return to work wage:                                                                         2. Training kinds: Start date: Projected end date: Training facility/employer:                                                                         Attach copy of the on-the-job training contract, if applicable. 3. Other services:       Training plan support documentation must include information required by OAR 436-120-0510. 4. Responsibilities of worker and counselor specific to this plan (not listed on the back of this form):       5. I understand my responsibilities under this plan and have received a copy of the plan support and both sides of this form. I understand that the Workers’ Compensation Division may review the plan. My signature authorizes the training facility to release grades to my counselor and insurer.       Worker Date       Counselor/intern Date       Cosigner, if applicable Date       Insurer Date Insurer phone:       6. Comments: For WCD use       In conformance with OAR 436-120             Consultant Date Not in conformance             Consultant Date Revised to conform             Consultant Date Optional             Consultant Date 440-1081 (1/17/DCBS/WCD/WEB) 1081 Responsibilities under Training Plan (OAR 436-120-0520) Worker will do the following: • Actively participate in all aspects of the plan. • Maintain regular contact with the counselor throughout plan development and as required in the plan. • Notify the counselor if problems develop and continue to attend training during attempts to resolve the issue. • Inform the counselor immediately if anything threatens to interfere with successful completion of the program. • Notify the counselor by the close of the next working day if the worker stops attending training for any reason. • Maintain a 2.0 grade point average each grading period in formal training. • Complete the courses outlined in the curriculum by the plan end date. • Consult with the counselor before adding or dropping courses. • Provide a written training report to the counselor by the fifth day of each month. • Give the counselor a copy of each grade or progress report within 10 days of receipt. • Meet any responsibilities agreed to in this plan. Counselor will do the following: • During plan development, provide resource materials about jobs, training programs (if appropriate), labor markets, and other related information to help the worker select a vocational goal; direct information gathering; and otherwise help the worker analyze and evaluate options. • Help the worker plan the curriculum and enroll. Contact the worker, trainers, and training facility counselors to the extent necessary to assure the worker’s participation and progress. • Contact the worker on a regular basis. • Monitor and evaluate the plan at least monthly. • Contact the worker’s trainers and training site counselors, as necessary, to ensure the worker’s participation and progress meet the requirements of the rules and are satisfactory to achieve the return-to-work objectives. • Immediately report potential problems in the program to the insurer, including additional needs of the worker. • Advise the insurer within one business day of learning of any circumstance indicating a probable or actual interruption in the worker’s entitlement to temporary disability benefits. • Provide job-search skills and job development as necessary. • Meet any responsibilities agreed to in this plan. Insurer will do the following: • Approve or disapprove this plan and notify the parties within 14 days of receiving the signed plan. • Contact the Workers’ Compensation Division within five days to schedule a conference if no plan is approved within 90 days of determining the worker entitled to a training plan. • Submit the plan and any addenda or amendments to the Workers’ Compensation Division. • Provide four months of job placement assistance after the worker completes training. • Provide a minimum of 60 days of return-to-work follow-up to ensure that employment is suitable. • Re-evaluate the plan and modify or replace it when appropriate to assure the worker’s success. • Provide further training if the initial plan is not successful in preparing the worker for suitable employment. • Meet any responsibilities agreed to in this plan. Important information to the worker about time-loss benefits • Time-loss benefits will continue while you are actively engaged in training, up to a maximum (usually 16 months). If your training program has been approved for a longer period of time than time-loss benefits may be paid, the insurer must notify you that the benefits may end before training ends. • If you do not follow this training plan, your training and time-loss benefits may end. • When you complete training and are medically stationary, the Workers’ Compensation Division or your insurer will determine your benefits. 440-1081 (1/17/DCBS/WCD/WEB)