Return To Work Plan Direct Employment {1083}

Submit to: Department of Consumer & Business Services Workers' Compensation Division 350 Winter St. NE P.O. Box 14480 Salem, Oregon 97309-0405 Date: Counselor (name, phone): VRO (name, city): Return-to-Work Plan; Direct Employment Worker: WCD file no.: Insurer: Claim no.: DOI: 1. Vocational objective(s): S.O.C/D.O.T. code(s): Expected weekly RTW wage: 2. Plan dates: Start date: Projected end date: 3. Specific services required to meet objectives: 4. Responsibilities of worker and counselor unique to this plan: 5. I understand my responsibilities under this plan and have received a copy of the plan support and both sides of this form. I understand that the Workers' Compensation Division may review the plan. Worker Date Plan developer Date Cosigner Date Insurer Insurer phone: Date 6. Comments: For WCD use In conformance with OAR 436-120 Not in conformance Consultant Date Date Date Consultant Date Revised to conform Consultant Optional Consultant 440-1083 (12/07/DCBS/WCD/WEB) 1083 American LegalNet, Inc. www.FormsWorkflow.com Responsibilities under Return-to-Work Plan Worker will do the following: · Maintain regular contact with counselor. · Fully participate in the return-to-work plan services. · Follow up on all job leads in a timely manner. · Accept suitable employment if it is offered and notify counselor immediately. · Promptly inform counselor of any problem that might affect participation. · Meet any responsibilities agreed to in this plan. Counselor will provide the following services in accordance with OAR 436-120: · Provide instruction on job-search skills, as necessary. · Provide job development, as necessary. · Provide timely, accurate progress reports to the insurer. · Meet any other responsibilities agreed to in this plan. Insurer will provide the following services in accordance with OAR 436-120: · Contact the Workers' Compensation Division to schedule a conference if no plan is approved within 45 days of determining the worker entitled to a direct employment plan. · File plan with Workers' Compensation Division. · Meet any other responsibilities agreed to in this plan. 440-1083 (12/07/DCBS/WCD/WEB) American LegalNet, Inc. www.FormsWorkflow.com