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State of California Division of Workers' Compensation STATEMENT OF DECLINE OF VOCATIONAL REHABILITATION BENEFITSINSTRUCTIONS: This form shall be signed and dated by the employee and the employee's representative (if any) when the employee declines the provision of vocational rehabilitation ser- vices and sent to the employer/insurer. When the choice to de- cline services occurs subsequent to the commencement of voca- tional rehabilitation services, this form shall be submitted by the employer/insurer to the Rehabilitation Unit with the Request for Conclusion of Rehabilitation Benefits Form RB-105- REHABILITATION UNIT USE ONLY EMPLOYEE NAME: (FIRST)(MIDDLE)(LAST)RU CASE # if any: NOTICE TO EMPLOYEE Employees who have had industrial injuries may be entitled to receive vocational rehabilitation benefits if they are likely to be precluded from returning to their employment and would benefit from the provision of vocational rehabilitation services. This benefit, known as vocational rehabilitation, varies with the employee's needs and abilities. This may include an evaluation to identify the type of vocational rehabilitation services which can help the employee to return to suitable employment. These services may involve changing the demands of the employee's usual job; assisting the employee to obtain new employment compatible with his/her abilities; or training the employee for a new occupation. When the employee is a qualified injured worker, all vocational rehabilitation costs are paid by the employer or its insurer. The employee continues to receive temporary disability indemnity payments during the period of entitlement to vocational rehabilitation services. The employee has the right to choose whether he/she will accept the provision of vocational rehabilitation services. Regardless of the employee's choice, other workers' compensation benefits will not be affected. If the employee declines rehabilitation benefits now, he/she may be able to request future consideration of these benefits within statutory time limits. The request must be in writing and submitted to the Rehabilitation Unit within one year of either a finding of permanent disability or approval of a compromise and release by the Workers' Compensation Appeals Board, or within 5 years from the date of injury. The Rehabilitation Unit will determine entitlement to services. STATEMENT OF EMPLOYEE I have read and understand this notice and I choose to decline the provision of vocational rehabilitation benefits. EMPLOYEE'S SIGNATURE: EMPLOYEE REPRESENTATIVE'S SIGNATURE (if represented): DATE:State of California DWC Form RB-107 (pre l/l/90) Rehabilitation Unit California Division of Workers' Compensation Form RB-107 STATEMENT OF DECLINE OF VOCATIONAL REHABILITATION BENEFITSPurpose:To record the employee's declination of rehabilitation services for injuries before I/1/90.Submitted by:Claims administrator. When submitted: When the employee chooses to decline vocational rehabilitation services. Where submitted: With the applicable local office of the Rehabilitation Unit. Form completion:Identifying data completed by claims administrator. Statement of employee completed by injured worker with signature of injured worker and attorney, if represented. Accompanying document: Request for Conclusion of Rehabilitation Benefits Form RB-105. Response to RU-103: The other parties shall have twenty (20) days to respond by forwarding their position, with supporting information, to the applicable Rehabilitation Unit district office with copies to all parties. Rehabilitation Unit action: If the employee objects to the Request for Conclusion, the Rehabilitation Unit shall, within 30 days, schedule a conference or otherwise obtain the employee's reason for objection with substantiating evidence and issue its decision. Copy:All parties.