Reset
Mail completed copy to: Department of Labor and Industry PO Box 64221 St. Paul, MN 55164-0221 (651) 284-5030 or 1-800-342-5354 (DIAL-DLI)
Plan Progress Report
PRINT IN INK or TYPE Enter dates in MM/DD/YYYY format.
P R 0 1
DO NOT USE THIS SPACE
1. DATE OF THIS REPORT
2. WID or SSN
3. DATE OF INJURY
4. EMPLOYEE NAME
5. EMPLOYEE ADDRESS
CITY
STATE
ZIP CODE
6. DATE OF REHABILITATION CONSULTATION: (#27 on R-2)
7. EMPLOYER NAME
8. EMPLOYER CONTACT PERSON
9. PHONE NUMBER
10. INSURER CLAIM NUMBER
15. QRC NAME
11. INSURER/SELF-INSURER/TPA
16. QRC FIRM
12. INSURER ADDRESS
17. ADDRESS
CITY
STATE
ZIP CODE
CITY
STATE
ZIP CODE
13. CLAIM REPRESENTATIVE
14. PHONE NUMBER 18. QRC #
19. QRC FIRM #
20. PHONE NUMBER
21. Is the employee released to return to work? 22. Current work status: 23. Is the plan still current? Not working Yes
Yes, Part time No
with restrictions
Yes, restrictions Seasonal layoff
without
Medical report date No If working, is this a temporary job? Yes No
Full time
Plan costs to date 24. Costs 25. Plan duration from plan filing date (in weeks) Duration to date + +
Other costs necessary to complete plan = Expected additional duration to plan completion = Yes No
Estimated total cost
Estimated total duration
26. Do barriers to successful completion of the rehabilitation plan exist?
If yes, list these on a separate sheet along with the measures to be taken to overcome those barriers, and attach it to this form.
This form is required to be filed 6 months after filing the R-2 (unless an R-3 is filed 15 days before or after 6 months have passed since the R-2 filing date). See Minn. Rules 5220.0450, subp. 3 A. Send copies to the employee, insurer, and attorney(s). Send to the date-of-injury employer if the goal of the rehabilitation plan is to return to work with that employer.
This material can be made available in different forms, such as large print, Braille, or on a tape. To request call (651) 284-5030 or 1-800-342-5354 (DIAL-DLI)/Voice or TDD (651) 297-4198. ANY PERSON WHO, WITH INTENT TO DEFRAUD, RECEIVES WORKERS' COMPENSATION BENEFITS TO WHICH THE PERSON IS NOT ENTITLED BY KNOWINGLY MISREPRESENTING, MISSTATING, OR FAILING TO DISCLOSE ANY MATERIAL FACT IS GUILTY OF THEFT AND SHALL BE SENTENCED PURSUANT TO SECTION 609.52, SUBDIVISION 3.
MN PR01 (5/08)