Fill and Sign the Report Workers Form

                                                                                                                                                                                                                                                                                   VOCATIONAL REHABILITATION PROGRESS REPORT # Claims Administrator: Employee: Address:Claim #- DOI: City/State/Zip: Employer: Contact Name: Report Date: Period Covered: Anticipated Plan Submission Date: Date Vocational Feasibility: Plan Goal: Plan Start Date: Plan Completion Date: Dates of Meetings/Appointments/Classes Attended: Dates of Missed Meetings/Appointments/ Classes: Services Provided: Summary of Activities and Comments: Recommendations/Plan of Action: Next Reporting Date: QRR (print name): Signature: Date: Telephone Number: Attachments: Copies Sent To: VR Initiated Pre 1998 VR Initiated Post 12/31/97 Phase I- $ Phase A: $ Phase II: $ Phase III: $ Phase 13- $ Report Prep Time: minutes Cum. Total: $ Cum. Total: $ State of California DWC Form RU-121 (9/98) Rehabilitation Unit California Division of Workers' Compensation Form RU-121 VOCATIONAL REHABILITATION PROGRESS REPORT Purpose: To report on the progress of the employee who is receiving vocational rehabilitation services. Submitted by: Qualified Rehabilitation Representative (QRR). When submitted: Reports are done no less often than once per month, unless otherwise agreed to, due to cap considerations. The QRR shall report to all parties within 10 days of the completion of services. Where submitted: To the claims administrator with copies to all parties. If the QRR were functioning as an Independent Vocational Evaluator (IVE), the RU-121 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 on the progress of vocational services. The 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.