Free IC31 - Illinois

ILLINOIS WORKERS' COMPENSATION COMMISSION REHABILITATION PLAN
ATTENTION. The employer, in consultation with the injured worker, shall prepare a rehabilitation plan when the employee has been unable to work for more than 120 continuous days or when it can be reasonably determined that the injured worker will be unable to resume his or her regular, pre-injury duties. The plan shall be updated at least every four months while the employee remains incapacitated or until the case is closed by the Commission. A copy of each document shall be given to the injured worker. See Section 7110.10 of the Commission Rules.

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Employee/Petitioner v.

Case # ________ WC ____________________

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Employer/Respondent

Attach the most recent medical report and provide an assessment of the medical care necessary for the petitioner to return to work.
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Is rehabilitation necessary for the employee to return to work? Yes ____ No ____

Explain below.

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If rehabilitation is necessary, address the need for each of the following: Medical evaluation
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Vocational evaluation

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Modified or limited duty _________________________________________________________________________________________
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Retraining

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Other

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Signature of petitioner Date

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Signature of person completing this form Date

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Name of petitioner (please print)

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Name of person completing this form (please print)

IC31 12/04 100 W. Randolph St. #8-200 Chicago, IL 60601 312/814-611 Toll-free 866/352-3033 Web site: www.iwcc.il.gov Downstate offices: Collinsville 618/346-3450 Peoria 309/671-3019 Rockford 815/987-7292 Springfield 217/785-7084