Closure Report {VR-2}

MARYLAND WORKERS' COMPENSATION COMMISSION VOCATIONAL REHABILITATION CLOSURE REPORT Claimant's Name: Practitioner: Date of termination of services: WCC Claim#: WCC Registration #: Date of Report: Yes No Have all parties been notified of termination of services within 5 working days? If "No," please explain why: Rehabilitation services provided: Enter service code(s) 01. Vocational rehabilitation counseling/coordination 02. Vocational evaluation 03. Vocational assessment 04. Medical case management/coordination Programs provided: Enter service code(s) 11. Direct job placement 12. On-The-Job Training program 13. Self employment 14. Job-club 15. FCE 16. Work hardening 17. Pain management programs 18. Job modification 19. Other: Reason for termination: Enter appropriate code 21. Returned to work with the same employer, same job 22. Returned to work with the same employer different job 23. Returned to work with a new employer, same occupation 24. Returned to work with a new employer, different occupation 25. Self employment 26. Return to work is not feasible (Explain) 27. Claimant declined rehabilitation services 28. Claimant was not actively participating in the rehabilitation program 29. Claimant moved out of state 30. Claimant declined job offers that were within the scope of the rehabilitation plan 31. Other: Comments/Explanations: If returned to work, complete the following: Pre-injury AWW: Current AWW: CERTIFCATION OF SERVICE I hereby certify that on the day of ,2 , I mailed, postage prepaid, a copy of the foregoing Vocational Rehabilitation Services Closure Report and any attached documentation to all parties and their attorneys. Signature Telephone Date 10 East Baltimore Street Baltimore, Maryland 21202-1641 410-864-5100 Email: info@wcc.state.md.us Web: http://www.wcc.state.md.us WCC Form VR02 (05.10) American LegalNet, Inc. www.FormsWorkFlow.com