Vocational Rehabilitation Job Retention Plan {BWC-3015}

Vocational Rehabilitation Job Retention Plan Injured worker name (Last) (First) (MI) Claim number Date of plan submission Return-to-work level of most recent job (check one) / / / / / Same job/Same employer Different job/Same employer Same job/Different employer Different job/Different employer Job retention 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 Signature of vocational rehabilitation case manager (VRCM) Initials of person verifying verbal approval Date signed / / / / / / / / Date signed Date signed Date signed I have received a copy of the Rehabilitation Agreement (RH-1) and my vocational rehabilitation job retention plan, and understand and accept their conditions. By signing this plan of service, I agree to participate in the services outlined in this plan to assist me in maintaining current employment. I agree to participate in all planned services as scheduled. My attendance is necessary to achieve the goal of staying at work. My attendance and active participation will be viewed as an example of my work behavior and my effort. Unexcused absences from scheduled services may result in 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 Issue identified Services planned and justification BWC- 3015 (Rev. May 3, 2016) Page |1 RH-47 Please have injured worker initial here. American LegalNet, Inc. www.FormsWorkFlow.com Vocational Rehabilitation Job Retention Plan Injured worker name (Last) (First) Date of plan submission Claim number / / Estimated cost $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Plan of services Type of service Service provider Estimated weeks Estimated service dates From To / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / Total weeks of services to date Total cost of all services to date BWC- 3015 (Rev. May 3, 2016) Page |2 RH-47 Please have injured worker initial here. American LegalNet, Inc. www.FormsWorkFlow.com