Free Download VR Return to Work Plan in PDF format - Vermont

Return to Work Plan Claimant Name:

State File #:

PART I
Date of Screening: Screener: VR Goal (This must be a specific job or job category): Physical capabilities for the proposed vocational goal have been reviewed with physician?

YES

NO

PART II
Return To Work Priority (How will the goal be achieved): Estimated Plan Completion Date:

PART III
Rationale For The Selection Of The Vocational Goal:

PART IV
OBJECTIVE 1: Services: Evaluation Method / Criteria: OBJECTIVE 2: Services: Evaluation Method / Criteria:

PART V
Costs:
Progress report filing timeframe:

PART VI
RESPONSIBILITIES WITH SIGNATURES:
Counselor: Claimant: Carrier:

CLAIMANT'S UNDERSTANDING:
This plan may be interrupted or terminated if you fail to fulfill your responsibilities to: Meet your responsibilities in carrying out this plan Perform job search activities identified in this plan Attend all appointments and scheduled activities Notify your counselor of any change which will impact on your ability to complete or participate in this plan Attain passing grades in any and all training Follow medical or other professional's instructions

FAILURE TO COOPERATE IN YOUR PLAN OR MAKING REASONABLE PROGRESS TOWARDS EMPLOYMENT MAY RESULT IN SERVICES BEING DISCONTINUED.

I have read and understand the contents of the vocational rehabilitation plan as described in this document and my signature represents that I agree to faithfully execute my responsibilities described in it.

SIGNATURES:
_________________________________________________________________ Employee Signature _______________________ Date

_________________________________________________________________ V R Counselor / Intern Signature

______________________ Date

_________________________________________________________________ V R Supervisor (If Applicable)

_______________________ Date

_________________________________________________________________ Claim Representative Signature

_______________________ Date

____________________________________________________________ Commissioner of Labor/Designee

_______________________ Date

Grounds for refusal to sign:

Rev. 02/07