Fill and Sign the Vra Dmin R Ulesrev 2 Hawaii Department of Labor Form

Pre l/l/94 Date of Injury Unrepresented Injured Employee QRR Waiver Discretionary Monies ! VOCATIONAL REHABILITATION PLANINSTRUCTIONS: This form shall be used for submitting a vocational rehabilitation plan to the Rehabilitation Unit for injuries in accordance with Labor Code Section 4638. For injuries prior to I/l/94, the claims administrator shall submit this signed form with medical and vocational reports to the Rehabilitation Unit for approval. For injuries occurring on or after l/l/94 where the employee is not represented by an attorney, the claims administrator shall submit this signed form, and all medical and vocational reports not previously submitted, to the appropriate Rehabilitation Unit office for approval. For injuries occurring on or after l/l/94 where the employee is represented by an attorney, the claims administrator shall submit this signed form attached to a copy of the Notice of Termination to the Rehabilitation Unit within 10 days of completion. If a Rehabilitation Unit case number has not been assigned, attach a completed Case Initiation Document (DWC RU-101). SECTION A EMPLOYEE NAME: (LAST)(FIRST)(M.I.)RU CASE #- ADDRESS:(STREET)(CITY)(STATE & ZIP) DATE OF BIRTH: CLAIMS ADMINISTRATOR: (FIRM)CLAIM #- ADDRESS:(STREET)(CITY)(STATE &ZIP) SECTION B OCCUPATION AT INJURY: EARNINGS AT INJURY: DATE OF INJURY: DESCRIBE TYPE OF INJURY AND MEDICAL LIMITATIONS: (Also identify medical report relied upon) SUMMARY OF EMPLOYEE'S EDUCATIONAL AND VOCATIONAL BACKGROUND AND EXPLANATION OF HOW TRANSFERABLE SKILLS HAVE BEEN USED IN SELECTION OF THE PLAN OBJECTIVE: INITIALSREHAB UNIT APPROVAL IS REQUIRED DUE TO: Check One REHABILITATION UNIT USE ONLY Mandatory Format State of California DWC Form RU-102 (9/98) page I of 4 1. Modified Job 2. Alternative Work 3. Direct Placement 4. On-the-job Training 5. Educational Training 6. Self Employment DATE VOCATIONAL FEASIBILITY DETERMINED: PLAN COMMENCEMENT DATE: EXPECTED COMPLETION DATE (Including placement assistance): # WEEKS OF TRAINING: # OF DAYS OF PLACEMENT ASSISTANCE: SECTION C VOCATIONAL OBJECTIVE: ESTIMATED WEEKLY EARNING UPON COMPLETION: Type of Plan WITH SAME EMPLOYER WITH NEW EMPLOYER DESCRIBE NATURE AND EXTENT OF REHABILITATION PLAN: INITIALSMandatory Format State of California DWC Form RU-102 (9/98) page 2 of 4 $ Weekly VRMA rate $ Withheld for attorney fees $ Total $ Dates: From Total $ Dates: From Transportation Expenses to be paid as follows: $ Total $ Total $ Total $ $ Phase II: Plan Development $ Phase A- $ Phase B- $ Plan Monitoring $ $ Total $ TOTAL ESTIMATE OF PLAN EXPENDITURES: $ Permanent Disability Supplement paid to date: $ Permanent Disability Supplement to be paid: $ Total $ Total $ Total $ Total $ BUDGET FOR VOCATIONAL REHABILITATION PLAN EXPENDITURES Identify incurred and estimated costs for this rehabilitation plan. For injuries on or after 1/1/94, the maximum expenditure for vocational rehabilitation expenses shall not exceed $16,000. RESOURCES TO EMPLOYEE Payment to Employee VRMA/VRTD paid prior to plan (including attorney fees) toVRMA/VRTD to be paid during plan (including attorney fees) toperPLAN EXPENDITURES Training/tuition fees, if any (specify recipient): $ Other costs (specify type, recipient and method of payment): $/$/Total $ $/Total $ $/Total $ FEES FOR EVALUATION, PLAN DEVELOPMENT & PLACEMENT (List Evaluation and Plan Development fees to date and estimated fees for Plan Monitoring and Placement) Phase I Evaluation DOI's on/after l/l/94 where VR was initiated on/after l/l/98 Phase III: Placement ADDITIONAL RESOURCES TO EMPLOYEE /week/weekOther resources to be provided to employee (Identify source and amount): $/$/SECTION D 1. List results of vocational testing, if any, and how they support the vocational objective. 2. Describe why this employee will be employable in the vocational objective of this plan. Include assessment of labor market. INITIALSMandatory Format State of California DWC Form RU-102 (9/98) page 3 of 4 SECTION E RESPONSIBILITIES OF THE CLAIMS ADMINISTRATOR: The claims administrator shall provide in a timely manner all vocational services and benefits necessitated by the agreed upon vocational rehabilitation plan and as required by the Labor Code. I verify that the insurer does not have a proprietary interest in the rehabilitation provider or facilities used in the development or implementation of this plan. Other:SignatureRESPONSIBILITIES OF THE EMPLOYEE: The employee shall be available and reasonably cooperate in the provision of vocational rehabilitation services. The employee shall arrive on time and participate in all scheduled activities; if for any reason the employee does not, he or she must immediately provide an explanation to the Qualified Rehabilitation Representative. The employee shall follow the requirements of all facilities and persons providing vocational rehabilitation services. The employee shall notify the Qualified Rehabilitation Representative about anything that may interfere with scheduled completion of this plan. Other:SECTION F VERIFICATION OF THE QUALIFIED REHABILITATION REPRESENTATIVE 1. This plan was developed by me as the Qualified Rehabilitation Representative or as an Independent Vocational Evaluator. It is my opinion that the services contained in this plan will provide the employee with the opportunity to return to suitable gainful employment. 2. The employee was not referred for services for evaluation, education or training to a facility in which 1, my spouse, my employer or co-employee has a proprietary interest or with which 1, my spouse, my employer or co-employee has a contractual relationship. Signature:Date:Finn Name &Address: SECTION GPLAN AGREEMENT Signature of the claims administrator and employee on this plan shall be deemed to be an agreement that the claims administrator and employee intend to comply with all of the plan's provisions. Failure of the claims administrator to provide in a timely manner all services required by the plan may result in the employee being entitled to additional services. Failure of the employee to comply with the provisions and schedules developed for this plan may result in termination of the employer's liability for rehabilitation services. I have read and understand all four pages of this plan and agree with all of the plan's provisions. NAME OF EMPLOYEE: SIGNATURE:DATE:NAME OF EMPLOYEE REPRESENTATIVE (if any): SIGNATURE:DATE:ADDRESS OF EMPLOYEE REPRESENTATIVE: PERSON AUTHORIZING THE PROVISION OF THIS PLAN ON BEHALF OF THE EMPLOYER: NAME:SIGNATURE:FIRM NAME AND ADDRESS: PERSONS SIGNING THIS SECTION SHALL ALSO INITIAL THE OTHER THREE PAGES IN INITIAL BOX. Mandatory Format State of California DWC Form RU-102 (9/98) page 4 of 4 Rehabilitation Unit California Division of Workers' Compensation Form RU-102 VOCATIONAL REHABILITATION PLANPLANS FOR REPRESENTED EMPLOYEES INJURED ON OR AFTER 1/1/94 Purpose:To document objectives and methods to be used to implement a proposed rehabilitation plan. Submitted by:Claims administrator. When submitted: The claims administrator submits the form with a RU-105 at the completion of the plan. Where submitted: With the applicable Rehabilitation Unit district office. A venue list is available to help you match the zip code of the employee's address with the correct district office. Form completion: See the following page for information on properly completing the form.. Please note: This form must be completed using type no smaller than 10 point. All information must be contained within the section provided. Accompanying documents: Within 10 days of plan completion, submit the RU-102 along with a RU-105 notice of termination. Include a RU-101 Case Initiation Document if the Rehabilitation Unit number is unknown. Medical and vocational reports should not be attached. Rehabilitation Unit action: Statistical recording. Copy:All parties. PLANS FOR UNREPRESENTED EMPLOYEES OR WITH A QRR WAIVER AND ALL PLANS FOR EMPLOYEES INJURED BEFORE 1/1/94 Purpose:To document objectives and methods to be used to implement a proposed rehabilitation plan. Submitted by: Claims administrator. When submitted: Immediately upon development of a rehabilitation plan which has been agreed to by the parties. If a waiver of Qualified Rehabilita- tion Representative is requested, whether represented or not, the plan must be submitted for approval. Where submitted: With the applicable Rehabilitation Unit district office. A venue list is available to help you match the zip code of the employee's address with the correct district office. Form completion: See the following page for information on properly completing the form. Please note: This form must be completed using type no smaller than 10 point. All information must be contained within the section provided. Accompanying documents: Include all supporting medical and vocational reports not previously submitted. Also include a RU-101 Case Initiation Document if the Rehabilitation Unit number is unknown. Rehabilitation Unit action: If disapproval is not made within 30 days of a properly documented plan, the plan is deemed approved. A notice of approval will only be issued in instances where disapproval was previously issued. Copy:All parties. INFORMATION ON HOW TO PROPERLY COMPLETE FORM RU-102 Form completion: Submit only if the employee is a Qualified Injured Worker. The RU-102 is prepared by a Qualified Rehabilitation Representa- tive (QRR). In filling out the form, avoid continuation of information to additional sheets. An extension of the information requested on the RU-102 to additional sheets should be limited to only the situation where there is an OJT agreement which describes the responsibilities of the parties and details of training. Page 1 - The QRR completes the required information. The box in the lower left hand comer is for the parties to initial to show their agreement with the plan. Employee level of participation must be described. Page 2- The QRR completes the information and the parties initial the page. The RU-102 is used for modified or alternative work plans when the offer of modified or alternate work is made subsequent to the initiation of rehab services. The box in the lower left hand corner is for the parties to initial to show agreement. If training, education, or tutoring is a part of the plan, the counselor must select a facility or program approved by the Council for Private Post Secondary and Vocational Education. Page 3-For injuries before 1/1/94 This page describes expected costs of the plan. There is not a legislatively required limit of $16,000 on total costs. For injuries on or after 1/1/94 The purpose of the budget is to plan the estimated expenditures. The total budget for rehabilitation services may not exceed $16,000 including QRR fees. For QRR fees, please refer to the fee schedule in the administrative rules. This page may be helpful as a counseling tool to show the injured worker that greater expenditures in one area must be balanced with savings in other areas or the development of additional monetary resources. Description of specific items on Page 3 VRMA/VRTD TO DATE refers to the rate and sum of VRMA payments made since the claims administrator sent the notice of potential eligibility and the injured worker requested rehabilitation services. VRMA/VRTD TO BE PAID refers to the rate and sum of VRMA payments during the plan. If the claims administrator is withholding for attorney fees, this should be calculated along with the actual weekly benefit payment so the worker will know how much he or she actually receives. Any allocation for TRANSPORTATION EXPENSES such as gas money or public transit tickets must be calculated. Any TRAINING/TUITION FEES and the training provider must be listed. OTHER COSTS such as clothing, tools, books, babysitting, relocation costs, or any other plan costs not itemized above on the form should be listed. FEES FOR EVALUATION, PLAN DEVELOPMENT AND PLACEMENT and other expenditures from the fee schedule must be listed. To ensure that total plan costs do not exceed $16,000 add the following: 1. VRMA/VRTD paid to date total 2. VRMA/VRTD to be paid total 3. Transportation expenses total 4. Total of plan expenditures 5. Total of fees for evaluation, plan development and placement The injured worker must ensure that he/she can meet his/her living expenses during the plan by adding the total weekly benefit payment to employee to the permanent disability supplement to be paid and any other confirmed financial resources which are listed. In addition, the injured worker can calculate expenditures for legal and rehabilitation fees by adding the total of the amount withheld for attorney fees and the total of fees for evaluation, plan development and placement. Regarding Section D-2, labor market surveys are not required. Labor market assessment should include information from the California Occupational Information System if it is available. The box in the lower left hand comer is for the parties to initial to show agreement. Page 4-This is the signature Page. Please note: The claims administrator is expected to sign in Section E as well as Section G. Please note: Any plan, whether the employee is represented or not, which provides funds to the employee to be disbursed at the employee's discretion or on a non-specific basis must be submitted for review to the Rehabilitation Unit to determine whether the plan is in conflict with Labor Code Section 4646 as required by AD 10126(b)(4).