Individual Written Rehabilitation Program {151}

Office of Education and Vocational Rehabilitation Lafayette City Center , 2 Avenue de Lafayette, Boston M A 02111 - 1750 I nformation Line (800) 323 - 3249 in Massachusetts ( 857 ) 321 - 7303 Outside Massachusetts www.mas s.gov/dia/oevr DIA Board #: Form # 151 Page 1 of 2 INDIVIDUAL WRITTEN REHABILITATI ON PROGRAM Please Print or Type Form 151 - Revised 7/2019 - Reproduce as needed Client Name: V.R. Provider: Street Address: Street Address: City, State, Zip: City, State, Zip: Tel. Number: Tel. Number: Date of Birth: V.R. Counselor: Pre - Injury Wage: $ Insurer: Vocational Goal Claims Rep resentative : DOT Code: Tel. Num ber: Date of Injury: FUNCTIONAL FUNCTIONAL LIMITATIONS (with supporting documents i.e. physical evaluation etc.): LEVEL OF SERVICE - Employment Goal: (Job Placement, Job Modifi cation, OJT, Training) VOCATIONAL VOCATIONAL SERVICES PLANNED & COST: FROM TO ESTIMATED COST Vocational Counseling and Guid ance $ Job Seeking Skills Training (with Resume prep.) $ Transferable Skills $ Job Modification (former Employer) $ Vocational Training (including formal classes) $ On - the - job Training $ Job Development & Placement $ American LegalNet, Inc. www.FormsWorkFlow.com Office of Education and Vocational Rehabilitation Lafayette City Center , 2 Avenue de Lafayette, Boston Massachusetts 02111 - 1750 Information Line (800) 323 - 3249 Massachusetts ( 857 ) 321 - 7303 Outside Massachusetts www.mass.g ov/dia/oevr DIA Board #: Form # 151 Page 2 of 2 Program n Program Justification : Submit a comprehensive case analysis of the injured worker, including such things as possible obstacles to rehabilitation, financial and family concerns, leve l of motivation, personal interests and avocations, and the necessary ingredie nts for a successful placement. Include injury restrictions, new job goal, why goal is appropriate, expected placement, salary and growth, injured VR provider responsibilities. (Attach extra sh eets if needed). : I will cooperate and make a good faith effort with all parties involved in my rehabilitation program. This includes the keeping of all appointments and ad herence to reasonable requests. I understand that any aspect of my program can be amended with good reason. SIGNED DATE CERTIFIED VR PROVIDER RESPONSIBILITY : I will be responsible for timely delivery of the above - referenced services and agree to emented without the approval of the Office of Education and Vocational Rehabilitation of the Department of Industrial Accidents . Should timelines or costs change in this program, I will notify the key parties and develop a program amendment. SIGNED DATE EMPLOYER/INSURER RESPONSIBILITY : I agree to pay for all reasonable and necessary VR services, and to monitor the costs and timeliness of services. SIGNED DATE OEVR RESPONSIBILITY : I will monitor the delivery of VR services to insure compliance with regulations and policy, ensure cost - effectiveness and quality of services. I agree to conduct team meetings to resolve any conflicts or issues amongst th e key parties with respect to VR in a fair, objective and timely manner SIGNED DATE VOC ATIONAL SERVICES PLANNED AND COST (CONT INUED ): FROM TO ESTIMATED COST Post - Placement Follow - up $ Transportation $ Program Completion Date: Total Est. Cost: $ American LegalNet, Inc. www.FormsWorkFlow.com