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Rehabilitation Rights and Responsibilities of the Injured Worker
DATE OF INJURY

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DO NOT USE THIS SPACE

WID or SSN

EMPLOYEE NAME

The purpose of vocational rehabilitation is to assist you (the injured worker) so that you may return to your former job, to a job related to your former employment, or to a job in another work field. The job should be physically appropriate and produce an economic status as close as possible to that which you would have enjoyed without disability. The first step in this return to work process is a Rehabilitation Consultation with a Qualified Rehabilitation Consultant (QRC) to determine if you qualify for rehabilitation services. If the QRC determines that you are qualified, the next step is the development of a rehabilitation plan. Your QRC will help you develop and implement this plan. Consideration will be given to your former employment, the current labor market and your qualifications, including transferable skills, previous work history, age, education and interests.

YOUR RIGHTS Under the provisions of the Minnesota Workers' Compensation Law, you (the injured worker) have certain rehabilitation rights. These rights include: · Selection of your own Qualified Rehabilitation Consultant (QRC). The employer/insurer will generally refer you to a QRC. You may choose your own QRC up to 60 days after a written rehabilitation plan is filed with the State. Any further change of QRC must be mutually agreed upon or determined to be in the best interest of the parties by the Commissioner or a compensation judge. When a QRC first meets or writes to contact you, he or she is required to disclose to you in writing, any affiliation or ownership interest between the QRC (or the QRC firm) and your employer/insurer or adjusting company. The QRC is also required to disclose to you and all parties to a case, any affiliation or business referral arrangement between the QRC (or the QRC firm) and any other parties to the case, including attorneys and doctors. If the QRC determines that you are eligible for vocational rehabilitation, a rehabilitation plan, which may include training if needed, will be developed. The rehabilitation services required to carry out the plan will be provided at no cost to you. The right to request a change in your rehabilitation plan. The right to receive a copy of your rehabilitation plan. The right to obtain a copy of any required progress records upon request. The right to request assistance from the Workers' Compensation Division of the Minnesota Department of Labor and Industry. If you have questions about your rehabilitation plan, call 651-2845032 or 800-342-5354. If there is a dispute about your eligibility for statutory rehabilitation services or the rehabilitation plan, you may file a Rehabilitation Request and the Department may schedule an administrative conference in order to resolve the dispute.
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WID or SSN

DATE OF INJURY

EMPLOYEE NAME
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YOUR RESPONSIBILITIES In addition to the above rights, you (the injured worker) have certain rehabilitation responsibilities under the workers' compensation law. These responsibilities include the following: · · · You must cooperate with reasonable medical and rehabilitation examinations and evaluations as ordered by the Commissioner. You must make a good faith effort to participate in your rehabilitation plan. Failure to do so may result in suspension or termination of your rehabilitation or monetary benefits. You must advise your QRC and insurance company of your wage, hours, employer and job title when you return to work with any employer and when your hours or wages change. This is necessary to accurately calculate your wage loss benefits and to ensure rehabilitation services are appropriate. Failure to accurately report wages earned while receiving workers' compensation benefits may result in civil or criminal consequences.

The statements below are requested to verify whether you received the documents listed and that the information on this form has been explained to you. You are not required to provide the information requested below or sign this form. Your workers' compensation benefits will not be affected if you choose not to provide the information or sign the form. This form will be filed with the Minnesota Department of Labor and Industry, and may also be provided to the Office of Administrative Hearings and law enforcement agencies. Employee, check any that apply: The above information has been explained to me and I have been provided with a copy of this form. I have received written notification from the QRC disclosing any affiliation or business referral arrangement the QRC or QRC firm may have with any parties to my case and a written explanation of any affiliation or ownership interest the QRC or QRC firm may have with my employer/insurer, and any other insurer or adjusting company. The QRC has informed me that he/she and the QRC firm have no affiliation or ownership interest or business referral arrangement with any parties to my case or any other insurer or adjusting company.
EMPLOYEE SIGNATURE QRC SIGNATURE QRC NUMBER DATE DATE

PROVIDING THE INFORMATION ON THIS FORM TO THE INJURED WORKER IS REQUIRED BY MINNESOTA STATUTES SECTION 176.102, SUBD. 4C AND MINNESOTA RULES, PART 5220.1803, SUBP. 1 AND 1A. THIS MATERIAL CAN BE MADE AVAILABLE IN DIFFERENT FORMS, SUCH AS LARGE PRINT, BRAILLE OR ON TAPE. REQUEST, CALL (651) 284-5030 OR 1-800-342-5354 (DIAL-DLI)/VOICE OR TDD (651) 297-4198. TO

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.

The QRC must sign and date this form at the first in-person contact with the employee, and must provide a copy to the employee and the insurer. The QRC must also provide a copy of this form to the Department of Labor and Industry. Minnesota Department of Labor and Industry Workers' Compensation Division PO Box 64221 St. Paul, MN 55164-0221 (651) 284-5032 1-800-342-5354 (DIAL-DLI)