Free Form VR-44: VR Plan - Nebraska

VR-44(04/09)

NEBRASKA WORKERS' COMPENSATION COURT
State Capitol Building; PO Box 98908; Lincoln, Nebraska 68509-8908

VOCATIONAL REHABILITATION PLAN
(Complete in Accordance with the Instructions on Page 4)

1. EMPLOYEE INFORMATION
Name:_____________________________________________ Social Security #:______________________ DOB:_________ Address: ___________________________________________ City:_______________________ State:____ Zip:_________ Phone:_________________ E-mail:_____________________ Employer:__________________________________________ Job Title:_________________________ DOT#____________ Hourly Wage (Time of Injury): $________AWW: ___________ Attorney? No__ Yes__ Name:____________________________
Phone:__________________________ Fax:________________________

2. COUNSELOR INFORMATION
Name:________________________________________________ Certificate #:_________ Company Name: _______________________________________ Address:______________________________________________ City:______________________ State:_____ Zip:___________ Phone:____________________________ Ext.: _______________ Cell Phone: (Optional) _______________________ Fax: _____________________________ E-mail:___________________________

3. INSURER INFORMATION
Company: _________________________________________ Address:___________________________________________ City:___________________ State: _____ Zip: __________ Claim #: ___________________________________________ Claim Rep: ________________________________________
Phone: ________________________________ Ext.___________ Fax:__________________________ E-mail: ________________________

4. MEDICAL (INJURY RELATED) INFORMATION
Date of Injury:__________________________________________ Diagnosis: _____________________________________________ ______________________________________________________ ______________________________________________________ MMI?
No ___ Yes ___ Date of MMI:

____________________

Injury Related Restrictions (Permanent): _____________________ ______________________________________________________

Attorney? No__ Yes__ Name:__________________________
Phone:__________________________ Fax:

____________________

_________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________

5. TYPE OF PLAN PRIORITIES

6. TRAINING/ VOCATIONAL GOAL
A. TRAINING GOAL:_________________________________ _____________________________________________________



NEW JOB SAME EMPLOYER



Training Provider:______________________________________ Address:______________________________________________ City: _________________________State: ______ Zip: ________ B. JOB GOAL (with DOT code): ___________________________ ___________________________________________________ __________________________________________________ C. HOURLY WAGE: Entry $__________ Average: $_________ Source(s) of wage data: _______________________________ ___________________________________________________ D. PLAN STARTS:_______________ENDS:_______________
MM/DD/YY MM/DD/YY

NEW JOB NEW EMPLOYER



GED ESL ABE OJT

TRAINING

Type of Training



Certificate Diploma AA Degree BA/BS Degree

Other_______________________________________
______________________________________________

7. BILLING INFORMATION

A. TUITION & FEES:

$___________________

Authorize to:________________________________________________________________________________________________ Address: _________________________________________________________________________________________________ City: ________________________________________State: ____________ ZIP: _________________

B.

REQUIRED BOOKS:

$ __________________

Authorize to: _________________________________________________________________________________________________ Address: __________________________________________________________________________________________________ City: _______________________________________ State: _____________ZIP: _________________

C.

GENERAL SUPPLIES: $ __________________

Authorize to: _______________________________________________________________________________________________ Address: ________________________________________________________________________________________________ City: _______________________________________ State: _______________ZIP: ___________________

D.

REQUIRED SUPPLIES: $ __________________

Authorize to: _______________________________________________________________________________________________ Address: ________________________________________________________________________________________________ City: ______________________________________ State: ____________ ZIP: ___________________

E.

SPECIAL FEES:

$ __________________

_______________________________________________________________________________________________________ Authorize to:______________________________________________________________________________________________ Address: _______________________________________________________________________________________________ City: ______________________________________ State: ____________ ZIP: ____________________________

F. TUTOR INFORMATION & FEES:
Hourly Rate: $______________ x Hours Per Week: _______________ x Number of Weeks: ____________ = Total: $___________________

Authorize to: __________________________________________________ SSN/FEIN:_____________________ Address: ________________________________________________________________________________________________ City: _____________________________________ State: ______________ ZIP: ______________________________

8. TRANSPORTATION, BOARD AND LODGING INFORMATION

Job Placement Mileage (Reimbursed at the current state rate. Maximum reimbursable mileage is 345 miles/week.) Training Mileage (Reimbursed at the current state rate. Maximum reimbursement will vary by month and by training facility.) Room and Board on-campus (Will be paid directly to the training facility. Local mileage is not reimbursable.) Room and Board off-campus where campus dorms are available (Reimbursed at campus dorm rates. Local mileage is not reimbursable.) Room and Board off-campus where campus dorms are not available (Reimbursed at court established rates. Local mileage is not
reimbursable.)

2

9. PLAN JUSTIFICATION

ATTACH THE PLAN JUSTIFICATION TO THIS FORM
PLAN JUSTIFICATION SHALL INCLUDE BUT IS NOT LIMITED TO THE FOLLOWING SECTIONS LABELED ACCORDINGLY AND PRESENTED IN THE ORDER SHOWN:

Section A: Background Information Section B: Vocational Assessment and Testing Section C: Priority Selection

Section D: Vocational Goal Selection Section E: Labor Market Information

SIGNATURES AND CERTIFICATIONS
(Read carefully before signing)

Vocational Rehabilitation Counselor: I hereby certify that this plan is reasonably necessary to restore the injured employee to suitable employment, and that all lower priorities as listed in section 48-162.01(3) of the Nebraska Workers' Compensation Act are unlikely to result in suitable employment for the injured employee. Counselor's Signature Date

Employee: I hereby certify that I have reviewed this vocational rehabilitation plan and the justification attached, and that I agree with the vocational goal and the proposed means to attain that vocational goal. I further certify that I will make a good faith effort to successfully complete this proposed plan within the specified time frame, and I understand that failure to participate or make satisfactory progress may result in cancellation of this plan. Employee's Signature Date

Employer/Insurer/Risk Management Pool: I hereby certify that the Insurer, Self-Insured Employer, Risk Management Pool agrees to pay to the employee weekly compensation benefits for temporary disability while he or she is engaged in this plan. Employer/Insurer/Risk Management Pool's Signature Date

Workers' Compensation Court Vocational Rehabilitation Specialist: I certify that I have evaluated this plan in accordance with section 48-162.01(3) of the Nebraska Workers' Compensation Act and that this vocational rehabilitation plan is hereby

APPROVED DENIED
Vocational Rehabilitation Specialist's Signature Date

3.

INSTRUCTIONS FOR COMPLETING THE VOCATIONAL REHABILITATION PLAN
1. EMPLOYEE INFORMATION: Complete all items in this section. DOT code is required for employee's time-of-injury occupation or an explanation must be provided in the Plan Justification section. The time-of-injury wage per hour and average weekly wage including overtime must be agreed to by all parties or an explanation must be provided in the Plan Justification section. 2. COUNSELOR INFORMATION: Complete all items in this section. Cell-phone number is optional, but recommended. 3. INSURER INFORMATION: Complete all items in this section. If employer is self-insured or a member of a risk management pool enter the name of the employer or pool. 4. MEDICAL INFORMATION: When completing this section rely on physician authored or endorsed information that is directly related to the work injury. Report only those restrictions that are permanent and injury-related. Any FCE results used must be endorsed by a physician. Do not rely solely on self-reported limitations. 5. TYPE OF PLAN: Select and check only one priority. If training is the priority selected, also check the type of training. No higher priority may be utilized unless all lower priorities have been shown to be "clearly inappropriate" and "unlikely to result in suitable employment for the injured employee." (§48-162.01(3)) 6. TRAINING/VOCATIONAL GOAL: If Job placement is proposed complete only parts B, C and D. If GED, ESL or ABE training is proposed, complete only parts A and D. If training other than GED, ESL or ABE is proposed complete this entire section, listing as the Training Goal the degree and major/area of focus and attach a detailed Plan of Study. If OJT is proposed complete this entire section using the same job title for both the Training Goal and the Job Goal. In part C, report the entry and the average (mean or median) wages for the Job Goal, identifying the geographic coverage area and source(s) of wage data. NOTE: If the projected wage after rehabilitation is significantly less than the time-of-injury wage, confirm in the Plan Justification that this has been discussed with the employee and the employee understands and voluntarily accepts this difference. 7. BILLING INFORMATION: Complete all applicable items in this section, identifying all costs expected. It is understood that costs for Tuition & Fees and Required Books (parts A & B) are estimates and subject to revision. General Supplies (part C) such as pens, pencils, notebooks, etc. are not to exceed $15.00 per term. Required Supplies (part D) must be supported by documentation that the supplies are required of all individuals in the same class or program. An itemized list must be attached and prior approval must be obtained. Special Fees (part E) are costs which may uniquely apply to an individual's plan, but must be reasonable and necessary. Prior approval must be obtained. Any Tutoring Services (part F) require prior approval and the number of hours requested should generally not exceed the number of scheduled classroom hours per week. Documentation of the need for tutoring may be requested. 8. TRANSPORTATION, BOARD AND LODGING INFORMATION: Check only one item in this section. If room and board is being requested, local commuting mileage from the student's temporary residence to the training facility is not reimbursable. Special one-way mileage between the student's permanent and temporary residence may be reimbursed at the beginning and end of each term. 9. PLAN JUSTIFICATION: A clearly legible statement titled Plan Justification must be attached to this form. It shall include at a minimum the following, labeled accordingly and presented in the order shown: A. Background Information: Provide a general summary of information relating to the employee's background, educational and vocational history, the occurrence and nature of the work injury, resulting physical limitations, and any other barriers to employment. B. Vocational Assessment and Testing Results: Identify, provide copies of, and summarize the results of all vocational, educational, and psychometric assessments administered and/or utilized in the course of developing this plan. C. Priority Selection: Section 48-162.01 states that no higher priority may be utilized unless all lower priorities have been clearly shown to be unlikely to result in suitable employment for the injured worker. Clearly state the factors used to rule out lower priorities and to select the priority proposed. Describe any research conducted that supports this selection. D. Vocational Goal Selection: Clearly explain how the specific vocational goal was selected, other goals explored and the reasons for ruling them out. Describe any research conducted, testing results, and/or other information used in making this selection. E. Labor Market Information: Sufficient labor market information must be submitted to establish (1) that the proposed job is available in the community and the projected outlook for that job, (2) that the employee meets the minimum qualifications for the job, in the case of job placement, or will meet the minimum qualifications after successful completion of training, (3) that the employee will be able to earn a wage comparable to what he or she was earning at the time of the injury, and (4) that the job is consistent with the employee's restrictions. Specific job titles, actual and/or projected openings, and actual and/or projected wages (starting wages and average wages) should be included. The labor market resources that were used to determine the job's availability must be identified. A labor market survey (i.e., contacts with employers and documentation of each contact) is not required in every case, but may be necessary in individual cases. 4.