Free VOCATIONAL REHABILITATION ANNUAL REPORT FORM - Vermont

Department of Labor Workers' Compensation Division PO Box 488 Montpelier, VT 05601-0488 (802) 828-2991 VOCATIONAL REHABILITATION ANNUAL SURVEY FORM

Date: Vocational Rehabilitation Counselor: Current Business Address: Phone: E-Mail: Self Employed Check if yes Employer:

Certification Number:

Requested Information Note: Please provide answers based upon your individual caseload for calendar year 2004. Calendar year 2004 runs from January 1, 2006 ­ December 31, 2006. 1. Caseload. Indicate your average caseload. Less than 10 10-40 40-70 70-100 More than 100

Number of claims in which you provided any vocational rehabilitation services. Number of claims in which you performed an entitlement assessment. Number of claims in which you provided vocational rehabilitation services but did not perform an entitlement assessment. 2. VR Costs and Expenses Billed. a. Indicate total costs for claims in which you found Claimant Not Entitled b. Indicate total costs for all other VR provided (EA's found entitled, all plans, amendments and all other VR costs billed in all cases other than Not Entitled). c. Indicate TOTAL costs of ALL vocational rehabilitation services and costs you billed for ALL claims in which you provided VR services over past year.

$ $ $

3. Plans; Return to Suitable Employment. For all cases in which you prepared an IWRP or amendment indicate the total number of cases in which : a. You prepared any IWRP or amendment b. The vocational plan was completed c. Claimant returned to suitable employment for 60 days or more d. Plan was completed but return to work for at least 60 days was not achieved 4. Closures. Total number of closures Voluntary withdrawals

5. Duration. For claims in which Claimant was found Entitled, indicate average length of time (in months) that vocational rehabilitation services were provided per claim: Average number of months service was provided:

REPORT DUE BY MARCH 30, 2007