Fill and Sign the Rehabilitation Workers Form

Board Use Only Reviewer Date Status      1 .                   4.             No Yes Diagnosis & Functional Restrictions             INITIAL REHABILITATION REPORT RELEASE TO RTW PHYSICAL RESTRICTIONS JOB ANALYSIS AT TIME OF INJURY ANALYSIS OF OFFERED JOB TRANSFERABLE SKILLS ANALYSIS       Type of Original Plan       Type of Previous Amended Plan       Date of Original Plan       Date       If services were interrupted in the Original/Amended Plan, state reason             If services are to be a continuation of a Previous Plan, state the need and justification for continuation             GEORGIA STATE BOARD OF WORKERS' COMPENSATION INDIVIDUALIZED REHABILITATION PLAN County of Injury SECTION I. IDENTIFYING INFORMATION 2. 3. Employee Name Social Security Number Date of Injury 5. 6. Occupation Date of Birth Catastrophic Injury 7. SECTION II. PLAN INFORMATION (Please check the appropriate blocks) TYPE OF PLAN VOCATIONAL SERVICES (Select One) RTW/SAME EMPLOYER JOB MODIFICATION GRADUATED PLACEMENT ON-THE-JOB TRAINING FORMAL TRAINING SELF EMPLOYMENT THE FOLLOWING DOCUMENTATION IS SUBMITTED FOR PLAN APPROVAL GIVE A STATEMENT (INDIVIDUALIZED TO THIS CASE) AS TO WHY SERVICES OF A REHABILITATION SUPPLIER ARE NEEDED COMPLETE THIS INFORMATION FOR AN AMENDED PLAN Willfully making a false statement for the purpose of obtaining or denying benefits is a crime subject to penalties of up to $10,000.00 per violation (O.C.G .A. §34-9-18 and §34-9-19). FORM WC-R2a REV. DATE 7/2000 R2a INDIVIDUALIZED REHABILITATION PLAN                                     JOB MODIFICATION     GRADUATED        RTW        PLACEMENT                     AVG WEEKLY WAGE AT TIME OF INJURY $       OR PER HOUR       ANTICIPATED WAGES $       WAGE LOSS $       HOURS WORKED PER WEEK AT TIME OF INJURY       PROPOSED FULL TIME WORK       OR PART TIME WORK                               Date       Date       Determined by       Evaluator             DATE COMPLETED             SS#       SECTION III COMPLETE THIS PART FOR THE CHECKED TYPE OF PLAN MEDICAL CARE COORDINATION (Catastrophic Cases Only) INDEPENDENT LIVING EXTENDED EVALUATION STATE SPECIFIC PROBLEMS STATE SPECIFIC GOALS SECTION IV. COMPLETE THIS PART FOR CHECKED VOCATIONAL SERVICESI . OJ T FORMAL TRAINING STATE REASONS FOR TYPE OF PLAN SELECTED 2. COMPLETE WORK AND WAGE INFORMATION: PER WEEK 3. OCCUPATIONAL OBJECTIVES 4. EDUCATIONAL/VOCATIONAL BACKGROUND 5. OCCUPATIONAL OBJECTIVES DETERMINED BY: TRANSFERABLE SKILLS VOCATIONAL EVALUATION SUMMARY OF VOCATIONAL EVALUATION 6. SUMMARY OF LABOR MARKET SURVEY (ATTACH REPORT) FORM WC-R2a REV. DATE 7/2000 R2a INDIVIDUALIZED REHABILITATION PLAN                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      SS#      SECTION V. Projected Services and Responsibilities Required to Meet Goals (Attach additional pages as needed) Initiation Completion Date Dat e Estimated Cost Payer Proposed Cost of Plan $ Willfully making a false statement for the purpose of obtaining or denying benefits is a crime subject to penalties of up to $10,000.00 per violation (O.C.G.A. §34-9-18 and §34-9-19). FORM WC-R2a REV. DATE 7/2000 R2a INDIVIDUALIZED REHABILITATION PLAN HAVE MAILED COPIES ON       Employee       Address             Employer       Address             Insurance       Adjuster       Address       Employee's       Attorney       Address       Employer's       Attorney       Address       Subsequent       Injury Trust       Fund Address       Registration No.       Expiration Date:       Telephone       Registration No.       Expiration Date:       Rehabilitation Supplier      Address       Catastrophic Intern (If Any)       EMPLOYEE COMMENTS ABOUT THIS PLAN:             DATE       EMPLOYEE'S SIGNATURE       ) YES ) NO ) YES ) NO SECTION VI. CERTIFICATE OF SERVICE (THIS SECTION MUST BE COMPLETED BY THE PRINCIPAL SUPPLIER) I CERTIFY THAT I HAVE DISCUSSED THIS PLAN WITH THE EMPLOYEE AND OTHER PARTIES TO THE CASE AND TO THE FOLLOWING PARTIES AT THE CURRENT ADDRESSES BELOW. DATE Telephone Telephone Telephone Telephone Telephone Telephone SIGNATURE This indicates that you have read or have had read to you the plan, not that you agree with the plan. DO ALL PARTIES AGREE TO THIS PLAN? ( ( Is this case applicable for Kid's Chance scholarships? ( If yes, submit application to Kid's Chance, Inc. ( SECTION VII. APPROVAL/OBJECTIONS, FIFTEEN (15) DAY NOTICE ABSENT WRITTEN OBJECTIONS WITHIN 15 DAYS OF THE DATE MAILED, THE REHABILITATION REQUEST IS APPROVED EFFECTIVE THEDATE OF THE CERTIFICATE OF SERVICE. NO FURTHER CORRESPONDENCE WILL BE ISSUED BY THE BOARD.IF THERE IS AN OBJECTION: (1)(2) THE OBJECTION MUST BE IN WRITING.IT MUST BE RECEIVED BY THE GEORGIA STATE BOARD OF WORKERS' COMPENSATION WITHIN 15 DAYS OF THE DATEOF THE CERTIFICATE OF SERVICE. (3) A CERTIFICATE OF SERVICE MUST BE COMPLETED STATING THAT COPIES OF THE WRITTEN OBJECTIONS WEREPLACED IN THE MAIL TO ALL PARTIES AND THE PRINCIPAL REHABILITATION SUPPLIER THE SAME DATE AS THECERTIFICATE OF SERVICE ANY OBJECTIONS RECEIVED BY THE BOARD WILL BE PROCESSED IN ACCORDANCE WITH O.C.G.A. §9-11-6 (e). FORM WC-R2a REV. DATE 7/2000 R2a INDIVIDUALIZED REHABILITATION PLAN