Fill and Sign the Oregon Return to Work 497323705 Form

Submit to: Department of Consumer & Business Services Workers’ Compensation Division 350 Winter St. NE P.O. Box 14480 Salem, Oregon 97309-0405 Direct Employment 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. Plan dates: 3. Specific services required to meet objectives:       Start date:       Projected end date:       The plan must include information required by OAR 436-120-0197(1). 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.       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 440-1083 (1/17/DCBS/WCD/WEB) 1083 Responsibilities under Direct Employment Plan (OAR 436-120-0197) Worker will do the following: • Maintain regular contact with the counselor. • Fully participate in plan services. • Follow up on all job leads in a timely manner. • Be an active participant in the job search. • Accept suitable employment if it is offered and immediately notify the counselor. • Promptly inform the counselor of any problems that might affect participation in the plan. • Meet any responsibilities agreed to in this plan. Counselor will do the following: • Provide instruction on job-search skills, as necessary. • Provide job development, as necessary. • Provide timely, accurate progress reports to the insurer. • Meet any responsibilities agreed to in this plan. Insurer will do the following: • Provide the worker with at least four months of direct employment services. • Contact the Workers’ Compensation Division within five days to schedule a conference if no plan is approved within 45 days of determining the worker entitled to a direct employment plan. • Provide return-to-work follow-up for at least 60 days after the worker becomes employed to ensure the work is suitable and to provide any necessary assistance that enables the worker to continue the employment. • Submit the plan and any amendments to the Workers’ Compensation Division within five days of plan approval. • Meet any responsibilities agreed to in this plan. 440-1083 (1/17/DCBS/WCD/WEB)