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File Size: 56.6 kB
Pages: 1
Date: May 23, 2008
File Format: PDF
State: Minnesota
Category: Workers Compensation
Word Count: 388 Words, 2,340 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.dli.mn.gov/WC/PDF/pr01.pdf

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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)