Vocational Rehabilitation Progress Report {BWC-3014}

Vocational Rehabilitation Progress Report Injured worker name (Last) Date of report submission Return-to-work level (check one) (First) Same job/Same employer Different job/Same employer Reporting period Job goal or job family Plan number (MI) Claim number / / / / / / Same job/Different employer Different job/Different employer Date of injury Date of referral Plan type Date of plan submission Select one Prepared by Signature of vocational rehabilitation case manager / / Date signed / / Has there been a change to comprehensive plan services? Yes No If yes, injured worker signature is required on this report. I have received a copy of this report and understand and accept that it indicates a change to services in my established vocational rehabilitation comprehensive plan that does not yet include a change in the job goal or job family. By signing this progress report, I acknowledge and accept this change to plan of services, I agree to participate in the return-to-work services outlined by this report with the intent of returning to work within my capacities and abilities. I acknowledge that if a change in my job goal or job family is needed, a new plan will be written. I agree to participate in services as scheduled in the authorization requests related to this plan. My attendance is necessary to achieve the goal of returning to work. 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 Days absent ­ excused Days absent ­ unexcused Days attended / / Attendance summary Expected attendance Attendance narrative Complexity issues (brief summary of issues currently being addressed or newly identified and plans to address these concerns) Injured worker's perception of progress Details of progress during the period Other information Recommendations and justification (Includes services to be authorized if needed) BWC- 3014 (Rev. May 3, 2016) Page |1 RH-46 When required, please have injured worker initial here. American LegalNet, Inc. www.FormsWorkFlow.com