Fill and Sign the Work Plan 497429734 Form

Original Modification                                                                                                ORIGINAL MODIFICATION Effective start date, 1st 52 weeks       Change start date to Interrupt plan on Continue time loss to LEP to start on             Change in costs Change in time frames Change in goal Change in training site Other (specify) Restart plan on                               End date, lst 52 weeks       Revision of disapproved plan Early plan termination                                                             L&I USE                                           Approved Disapproved             1st 52 WEEK PERIOD RETURN TO WORK PLAN TIME ENCUMBRANCE Department of Labor and Industries This form must be filled out by a Vocational Rehabilitation Counselor who has received a referral from the State Fund. Date of this request Claim number Vocational counselor or Intern VRC or Intern, ID # Vocational counseling firm's name Phone number Injured worker's name Date of injury Address Provider # & branch Home address Phone number City/State ZIP City/State ZIP Type of Request: Plan Dates Requested LEP to end on Goal DOT Census Method Training site Contact person Phone Date signed VRC or intern ID# Signature, VRC or x ONLY For Dept Use Only Claim Manager Date signed Phone No. Signature F245-353-000 (FPDF) 1st 52 wk rtw plan time encumbrance 8-00 INDEX: VPLAN