Free untitled - Minnesota

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)

Retraining Plan
PRINT IN INK or TYPE Enter dates in MM/DD/YYYY format.
E P 0 4

DO NOT USE THIS SPACE

Private or confidential data you supply on this form will be used to process your workers' compensation claim. The data will be used by department of labor and industry (department) staff who have authorized access to the data, and may be used for state investigations and statistics. You may refuse to supply the data, but if you refuse your claim may be delayed or denied, or the form may be returned to you. The data will be made part of the department's file for your claim and may be supplied to: anyone who has access to the file or the data by authorization or court order; the employer and insurer for your claim; the office of administrative hearings; the workers' compensation court of appeals; the departments of revenue and health; and the workers' compensation reinsurance association.

WID or SSN EMPLOYEE NAME EMPLOYER NAME INSURER/SELF-INSURER/TPA INSURER CLAIM NUMBER

DATE OF INJURY

CLAIM REPRESENTATIVE

PHONE NUMBER

Pre-injury job title Occupational goal(s) Certificate/Degree program title School name Program length (weeks)

Pre-injury wage

Current compensation rate

Anticipated wage (from Labor Market Survey) Program start date City, State to Program completion date

ITEMIZED COSTS: * Explain (for example, tutoring, board and lodging) Tuition/Lab/Activity fees Books/Tools Special/Unique costs* Custodial Day Care Travel/Parking Total retraining costs (excluding wage benefits)

REQUIRED ATTACHMENTS: Pursuant to Minn. Rule 5220.0750, subp. 2(H), the following items MUST BE ATTACHED. a. Course syllabus/class titles. b. Physical requirements of the job for which the employee is being trained. (On-site job analysis is preferred.) c. Medical information that the training and the occupational goals are within the employee's restrictions. d. Test results which support course choice. e. Recent labor market survey.
MN EP04 (9/08) (over) cc: Employee, Insurer

RETRAINING RATIONALE: see Minn. Rule 5220.0750, subp. 2(F)

ACCEPTED PLAN: If all parties are in agreement with (and have signed) this Retraining Plan, submit it to the Department with the required attachments for approval or denial (see Minn. Rule 5220.0750, subp. 5).
Employee Signature Insurer Representative Signature QRC Signature QRC Number Print or type name Print or type name Print or type name Phone number Phone number Phone number Date Date Date

INSTRUCTIONS TO QRC NOTE: Retraining is limited to 156 weeks. DISPUTED PLAN: To resolve a disputed Retraining Plan, call the Department's Benefit Management and Resolution Unit at (651) 284-5032 and/or file a Rehabilitation Request (see Minn. Rule 5220.0950). DO NOT SUBMIT A DISPUTED PLAN to the Department without attaching it to a Rehabilitation Request, unless a Rehabilitation Request has been filed or will be filed by another party.
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. For Department Use Only Approved DLI Representative Signature Reason for denial: Denied Print or type name Phone number Date