Vocational Rehabilitation Assessment Plan {BWC-3011}

Vocational Rehabilitation Assessment Plan Injured worker name (Last) Date of plan submission Return-to-work level (check one) (First) Same job/Same employer Different job/Same employer (MI) Claim number / / / / / Same job/Different employer Different job/Different employer Assessment plan number Date of injury Date of referral Job goal or job family Allowed conditions / Plan of service approval Verbally approved by injured worker awaiting managed care organization (MCO) approval Authorized by Denied by Prepared by Signature of MCO representative Signature of MCO representative Initials of person verifying verbal approval Date signed / / / / / / / Date signed Date signed Date signed Signature of vocational rehabilitation case manager / I have received a copy of the Rehabilitation Agreement (RH-1) and my vocational rehabilitation assessment plan. I understand and accept their conditions. By signing this plan of service, I agree to participate in the assessment activities outlined in this plan to evaluate my employability and return-to-work service needs. I agree to participate in all planned services as scheduled. My attendance is necessary to evaluate my need for further vocational services. My attendance and active participation will be viewed as an example of my work behavior and my return-to-work effort. Unexcused absences from scheduled services may result in a reduction of living maintenance or possible discontinuation of rehabilitation plan services. Warning: Any person who obtains compensation or benefits from BWC or self-insuring employers by knowingly misrepresenting or concealing facts, making false statements, or accepting compensation or benefits to which he/she is not entitled, is subject to felony criminal prosecution for fraud. Date signed Signature of injured worker Accepted by // X Referral questions Services planned with rationales BWC- 3011 (Rev. May 3, 2016) Page |1 RH-43 Please have injured worker initial here. American LegalNet, Inc. www.FormsWorkFlow.com Vocational Rehabilitation Assessment Plan Injured worker name (Last) (First) Date of plan submission Claim number / Plan of services Type of service Service provider Name of contact person and phone Frequency / / / / / / / / / / / / / / / / Service dates From To / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / Estimated cost $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Total weeks of services to date Total cost of all services to date BWC- 3011 (Rev. May 3, 2016) Page |2 RH-43 Please have injured worker initial here. American LegalNet, Inc. www.FormsWorkFlow.com