Vocational Rehabilitation Counselor Handbook

Division of Federal Employees' Compensation (DFEC)

Part 12

Part 12 – Communication and Documentation
Paragraph and Subject	Date	RCHB Trans. No.
Table of Contents	02/15	15-01
1. Overview	02/15	15-01
2. Communicating with the IW	02/15	15-01
3. Communicating with the RS	02/15	15-01
4. Communicating with the CE	02/15	15-01
5. Documenting RC Communication and Intervention	02/15	15-01
6. Progress Reports	02/15	15-01
7. Specific Rehabilitation Reports	02/15	15-01
Exhibit 1: Monthly Progress Report	02/15	15-01
Exhibit 2: Initial Evaluation – First Progress Report	02/15	15-01
Exhibit 3: Closure Report – Employment, Previous Employer	02/15	15-01
Exhibit 4: Closure Report – Employment, New Employer	02/15	15-01
Exhibit 5: Closure Report – Wage Earning Capacity Data Included	02/15	15-01
Exhibit 6: Closure Report – Other	02/15	15-01

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1. Overview. The goals of vocational rehabilitation are best achieved through a team approach, with the Injured Worker (IW), Rehabilitation Counselor (RC), Rehabilitation Specialist (RS), Claims Examiner (CE) and other participants working together to facilitate a successful return to work. A working relationship derived from an open and cooperative dialogue serves as a catalyst in establishing this desired team approach.

This part of the handbook is focused specifically on communications and documentation. Successful dialog is achieved through regular and purposeful written and/or verbal communications. When determining the need for, and mode of, a communication, consideration should be given to what information needs to be communicated and whether or not the information requires immediate attention, action and/or response.

As an additional resource, individual Parts in this RC Handbook describe required communication, documentation and reporting time frames for each of the individual rehabilitation program statuses. See also RC Handbook, Part 2, Exhibit 1: Vocational Rehabilitation Timeliness Standards and Status Criteria.

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2. Communicating with the IW. Effective communication forms the core of the RC/IW relationship in the vocational rehabilitation process. As such, the RC should plan for and engage in various means of communication with the IW in order to convey program requirements while building and maintaining rapport to facilitate a productive process.

a. When/How to Communicate with the IW. Personal (face-to-face) contact, telephone and/or email are usually the primary vehicles of communication with the IW. Federal disability non-discrimination law requires the program to be accessible and to use an interactive process to determine whether communication assistance or accommodation is needed by various participants in the claims process. See FECA Bulletin No. 12-05 (issued April 20, 2012).

(1) Face-to-Face. It is important for the RC to have personal (face-to-face) contact with the IW as much as is feasible. While always valuable, this is particularly important at transition points, such as the start of rehabilitation services and at the beginning and ending of training or placement programs to maximize opportunities for provision of support and direct gathering of information. Ongoing personal contact may reduce the chances of interruption of the rehabilitation process. All face-to-face meetings must occur in accessible locations.

(2) Telephonic and email contacts are productive as a means of ongoing communication between in-person meetings and/or when in-person appointments are not possible due to geographic or other considerations. IWs with impairments may require communication assistance and accommodation.

(3) While not to be relied upon as a primary method of communication, the traditional mail system may be utilized by the RC for specific tasks (e.g. appointment letters). Also, formal notices and courtesy copies of forms or documents utilized in the rehabilitation process may be sent by mail.

b. Discussion of Communication with the IW. At the RC's first meeting with the IW, the issue of communication should be addressed including:

(1) The expectation of regular and ongoing communication throughout the rehabilitation process between the RC and IW, including the IW's equal responsibility in maintaining such;

(2) The RC's responsibility to maintain communication and provide information to the RS and CE. This can include information about type and status of services, barriers to reemployment and issues of non-compliance;

(3) The best means of communication between the IW and RC with consideration given to the IW's access (to telephone, computer, etc.), convenience, need for accommodation and privacy of information; and

(4) A strategy and/or schedule for communication and maintaining contact.

c. Permanency of Documentation. The RC and IW should also discuss that the RC's progress reports and other formal reports and documentation developed and utilized throughout the rehabilitation process are forwarded to the DFEC and become a part of the IW's permanent record (called the FECA case file or the FECA case record).

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3. Communicating with the RS. The RS serves not only as the coordinator of rehabilitation services and the RC's primary point of contact, but also as the liaison with the CE and, as needed, with the IW or other stakeholders in the rehabilitation process.

As such, the RC will maintain regular contact with the DFEC RS throughout the vocational rehabilitation process through both formal reports and informal, interim communications. This will ensure that the RS is aware of all factors that may affect successful rehabilitation and which will facilitate timely supports or interventions by the RS and/or CE. Individual Parts in this Handbook describe required documentation, reporting and communications time frames in the different rehabilitation phases. The RC, however, is not limited to communications within these required time frames and may contact the RS more often, as necessary, to convey information or to request guidance or support.

a. When/How to Communicate with the RS. The primary vehicles of communication with the RS include email or telephonic communication, monthly progress reports and the Form OWCP-44, Rehabilitation Action Report.

Usually, the required monthly rehabilitation report will document the activities of the RC for that time frame, including any informal discussions with the RS. Additional documentation and/or contacts of both a routine or emergency nature should be provided as needed. It is expected that the RC will use his/her professional judgment as to when contact is necessary and follow the specific directions of the RS.

When considering contacts to the RS, the RC should consider whether immediate RS intervention is necessary or if the information can be relayed in a regular report (i.e. does the RC need additional information or insight that is best obtained immediately from the RS?)

Examples of situations and vehicles by which the RC can/should contact the RS are as follows:

(1) Form OWCP-44, Rehabilitation Action Report. The Rehabilitation Action Report is a form meant to be used to alert the RS to specific situations which need immediate action or intervention. Examples of situations in which the RC should contact the RS via the Rehabilitation Action Report are:

(a) A job offer is made to the IW (forward the Form OWCP-44 along with the job offer and position description);

(b) The IW accepts a job offer and is returning to work;

(d) There is a change in medical status reported by the IW or medical provider(s) which is significant enough to affect the IW's rehabilitation plan or return to work (forward Form OWCP-44 along with the medical evidence substantiating the change); and/or

(e) The IW is not participating and/or is obstructing vocational rehabilitation services (e.g. not appearing at scheduled meetings, not returning attempts at contact, not carrying out agreed upon actions or scheduled services, or any other IW actions that jeopardize or delay a rehabilitation plan or return to work). Describe the situation and the specific type of noncooperation or problem on the Form OWCP-44 and provide any factual evidence which supports non-cooperation (such as written notification from providers or educators of missed appointments or classes). See Part 11 of this handbook regarding non-cooperation.

(f) Any other circumstances or situations in which the RS requests that the RC alert him/her by using Form OWCP-44.

(2) General Reasons for Contact. Examples of situations in which the RC should contact the RS by telephone, email or other appropriate means include:

(a) The RC has requested an RS action but has not received a response from the RS;

(b) A case is referred without medical information and without instructions for obtaining that information;

(c) The previous employer is not being responsive to attempts at the reemployment effort and/or has stated that reemployment is not an option;

(d) The RC has questions regarding medical status or diagnoses; or does not know whether medical evidence has been considered by the CE;

(e) The RC believes an extension of calendar time or professional hours is needed at any stage of the rehabilitation process;

(f) The status of the case should change;

(g) The RC believes that Assisted Reemployment or other employment incentives may be beneficial in the IW's job search process;

(h) Significant changes, challenges or problems during any stage of the rehabilitation process which may impact the success of reemployment;

Note - When contacting the RS regarding conflicts or case problems, the RC should, if possible, be ready to provide recommendations for resolution.

(i) The RC has general questions and/or suggestions about how to proceed with a case, and/or

(j) Legal issues arise including subpoenas, requests for testimony or the release of information or documents, or for attorney participation in the rehabilitation process (the RC should always request guidance from the RS prior to responding to these matters);

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4. Communicating with the CE. The CE is responsible for all case management decisions and actions related to an IW's FECA claim, including adjudication decisions related to rehabilitation and return to work. While the RC's primary point of contact is the DFEC RS, direct communication between the RC and CE may sometimes occur either individually or in conference with the RS and other participants.

The RC should follow the guidance of the RS as to whether to contact the CE directly and, if approved, as to the use and frequency of such communications.

The RC may need or benefit from direct communication with the CE as follows:

(a) For clarification or interpretation of medical reports or work restrictions;

(b) To discuss a change in IWs medical status and determine whether there is a need for a second opinion medical examination or additional medical services;

(d) For incidents of non-compliance or apparent lack of cooperation, to discuss intervention options including possible warnings or sanctions;

(e) In a team conference, to discuss the IW's questions related to claims and rehabilitation; to encourage participation or problem-solve; and/or

(f) To address emergencies related to claims matters (e.g. the IW receives a job offer while the RS is on vacation/leave for a period of time).

As stated, while DFEC encourages a team approach to vocational rehabilitation, it is important for the RC to use the RS as the primary point of contact. The RC should always advise the RS of any direct communications with the CE and outcomes of such.

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5. Documenting RC Communication and Intervention. The DFEC Vocational Rehabilitation Program requires the RC to initiate and maintain regular contact with the RS and IW and to communicate as necessary with medical and rehabilitation providers, employers and other participants in the rehabilitation process.

The RC is also required to submit to the RS particular types of communications at specified intervals throughout the provision of services. The following paragraphs focus on the avenues of communications available to the RC, identify the timing for submission of particular communications, and provide parameters regarding informational elements that should be documented within the communications. All case-related communications become a part of the permanent case file record as submitted.

Note: The RC should follow the directions of the RS in regard to the method of transmission for documents which are time-sensitive or require the RS's immediate attention.

a. ECOMP – Employees' Compensation Operations and Management Portal - is a DFEC secure web portal that allows the RC to upload case-related documents and/or communications directly into a FECA case file. The document is viewable to the RS within 4 hours of it being uploaded in the ECOMP portal. Submission through ECOMP is the preferred method for RC transmissions of documents which are not associated with RC billing. Reports and documents associated with RC billing, such as progress reports, receipts or invoices must be transmitted through the OWCP Central Bill Processing (CBP) system.

b. Emails are a convenient, expedient method of communicating with the RS or others. The RC may use this mode to update the RS with time-sensitive case information or as a means of relaying or seeking information as needed otherwise. However, all email transmissions require special care in the dissemination of Personally Identifiable Information (PII). The requirements regarding email communications are detailed in Part 14 of this handbook.

c. Telephonic communication may also serve as an effective means of general communication, relaying important case-related concerns and/or bringing an issue requiring immediate review and/or action to the attention of the RS. The RS will then document the case file with a summary of the conversation.

The RC should provide a concise summary of telephonic communications with the IW and others in the monthly progress report.

d. Letters sent by the RC to the IW, previous Federal employer, medical, rehabilitation provider(s) or other participants are documents that are to be included as part of the official case file. It is important that all letters generated by the RS identify him/her as a contracted vocational rehabilitation professional working as a liaison for a specific FECA claim. The case file number should be included on all RC letters. Copies of all letters should be submitted to the RS.

e. Formal written reports should be formatted and typewritten and should be submitted as per the required time frames. For optimal imaging quality, it is recommended that reports be typed in a professional style type (such as Arial style) using a 12 point font.

f. OWCP Central Bill Processing (CBP) system - is a DFEC secure web portal that allows for the uploading and submission of documents related to RC billing. This information is viewable by the RS within several hours. Submission through CBP is the method for transmission of RC bills. The RC should follow the direction of the RS regarding the types of documents to transmit via the CBP. See Part 13 of this handbook for further information.

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6. Progress Reports - General.

a. Overview. Progress reports are one of the RC's primary means to communicate information to DFEC staff about the status and progress of a rehabilitation plan. This is also the primary means to document the RC's provision of services. All progress reports become a part of the IW's case file.

Progress reports are used to document all phases of service provision – the initial evaluation; interim/ongoing progress and communication; and closure. The required informational elements in all progress reports are consistent although the initial evaluation and closure reports may include additional elements as well.

The Initial Evaluation and Closure Reports are discussed in more detail at the end of this Part.

b. Progress Report Due Dates.

(1) The initial progress report is due in the District Office no later than 30 days from the date of referral.

(2) Thereafter, progress reports are due every 30 days, subsequent to the end date of the initial progress report, and should continue through the identified closure date.

(3) If there has been no significant activity during the service period, a report must still be filed. This should be a rare occurrence.

c. Progress Report Submission. All RC reports, including progress reports, are submitted along with any relevant records or documentation via the OWCP CBP system at the time of billing, unless otherwise stipulated by the RS. The RS will not authorize payment of bills without first reviewing the accompanying progress report which must justify professional hours and costs. Document attachments that are not compatible with the CBP system (and which will not upload) may be submitted via alternative methods, as per the RS's instruction.

d. Progress Report Content Summary. The content of the rehabilitation Progress Report should document RC and IW activities and outcomes, milestones, the RC's assessment of progress to date, a recommended plan of continued action and the RC's explanation and justification for such actions.

Progress reports should build on one another as the rehabilitation effort proceeds, avoiding repetition and focusing on new information from one service period to the next.

The report should include required informational elements, as specified in the following paragraph, as well as a narrative which details and discusses actions and outcomes achieved over the course of the service period.

The narrative should be concise, objective and professional in tone and avoid use of professional acronyms and jargon.

e. Elements of the Progress Report. Each Progress Report should contain the following items:

(1) Identification of the type of report being submitted (Initial Evaluation, Progress Report or Closure Report).

(2) The IW's name and case file number.

(3) Dates of the reporting period (Each report should cover 30 days and beginning and end dates should not overlap).

(4) RC's name and contact information.

(5) Rehabilitation Status - Plan Development; Placement – Previous Employer; Placement – New Employer; Training; Self-Employed; Medical Rehabilitation; Interrupted; Assisted Reemployment; Employed; Post-Employment Services; or Closed.

(6) Status Expiration – Date that the current rehabilitation status is expected to expire.

(7) Rehabilitation Costs. This section contains the rehabilitation costs incurred in the following format:

$_____FOR CURRENT STATUS $_____TOTAL COSTS TO DATE

(8) Professional and Non-Professional Hours: This section contains the number of professional and non-professional hours used in the following format:

______FOR CURRENT STATUS _____TOTAL HOURS TO DATE

(9) RS Actions/Responses Required. This section is utilized if the RC is in need of a response from the RS regarding authorization or action on the case. For example, the RC is submitting a rehabilitation plan for approval; submitting a request for change or extension of status; requesting authorization for additional professional hours; or notifying the RS that a job offer is included.

The Rehabilitation Action Report, Form OWCP-44, should also be utilized for situations (as specified on the form) which require immediate response from the RS.

(10) Synopsis of activities and contacts. This section contains a concise chronological summary of the RC's contact and activities with the IW, potential employers or any other relevant parties during the service period. Each contact description in the summary should be brief and need not be in narrative form. It must, however, include the date of contact, identity of the party or parties, activity and outcomes, and the amount of professional time expended. All contacts, regardless of length, should be reported and should match the billing for the reporting period.

The types of contacts and activities to list include:

(a) Meetings with the IW – list dates, types of contact (telephone, in-person visit, etc.) and the results;

(b) Meetings with rehabilitation service or training providers – list dates, types of contact and outcomes;

(c) Employer Contacts – list all and indicate the employer's name and address, the types of contact (telephone or visit) and the results;

(d) Job Interviews – summarize results and provide DOT job title and number; and

(e) Job Offers – summarize all offers and indicate whether the job duties accommodate the IW's work restrictions.

Examples of contact summary entries, to include dates and number of hours, include the following:

Met with Ms. Smith to review and edit job resume. The resume looks good and Ms. Smith appears eager to return to work.
Met with Ms. Smith and Ms. West, of Crate's Barrel Co., Wheeling, WV. They have an opening for a Data Entry Clerk (DOT #203.582-054) which is compatible with Ms. Smith's training and experience. Salary: $11.94 per hour. Job requires infrequent lifting up to 10 pounds, is sedentary, alternates sitting, standing and walking. Met with Ms. Smith and Ms. West before and after job interview. No promises were made, but prospects are promising. While a physical clearance is required, the job meets all the work restrictions outlined by Ms. Smith's attending physician.
Received call from Ms. Smith. She has a follow-up interview with Crate's Barrel. We both agreed that she should not be accompanied by RC. She will call me immediately after job interview.

(11) A narrative assessment and discussion of rehabilitation services and RC interventions to date including:

(a) Planned goals /actions achieved or not achieved during the reporting period.

(b) Barriers/Interventions. If goals or expected actions were not achieved or completed, what prevented the IW from fulfilling the goals. Discuss barriers and plans for intervention.

(c) Recommendations and Justifications. Includes reasons and explanations for any new recommendations, such as a change in the short or long range goal, direction or status of a rehabilitation plan, and for time and funding increases that exceed the original plan allowances. Any plan change, time frame or funding increase is subject to RS approval. A change to Placement – New Employer or Training must have written approval from the RS on the Form OWCP-3.

(d) The RC's plan of action for the next 30 days. Discussion of rehabilitation activities and goals to be achieved during the next reporting period (i.e. planned work site visits and/or attendance at medical provider appointments).

(12) Probability of Success. In this section, report any changes in, or new information related to, the probability that the IW will successfully complete the rehabilitation plan. The RC may report "No Change" when the probability remains the same as it was in the previous reporting period.

(13) Short and Long-Term Goals. This section details the short and long-term goals which are in accordance with the overall plan, and assigns time frames for their completion.

(14) Justification for Purchase of Equipment. If the RC recommends purchase of equipment to better accommodate the IW's work restrictions (e.g. telephone headset or modified keyboard) or to otherwise support the rehabilitation plan, the justification for purchase must be provided.

Exhibit 1 – Progress Report Sample - provides an example of a monthly Progress Report, which incorporates the associated required elements.

g. The Initial Evaluation. The Initial Evaluation is the first rehabilitation Progress Report that the RC is required to submit to the RS. As stated, it is due within 30 days from the date of referral.

In addition to the elements documented in the paragraphs above, the narrative should include:

(1) A comprehensive discussion of the IW's current situation – work, home, family, personal or social issues that may impact the return to work effort;

(2) Medical diagnoses, status and work restrictions;

(3) Past work experience, education and potentially transferrable skills; and

(4) Information regarding the IW's questions and/or concerns regarding return to work.

Exhibit 2– Initial Evaluation, First Progress Report Sample - provides an example of an Initial Evaluation Report, which incorporates the associated required elements.

h. The Closure Report. A Closure Report is the RC's final report for the rehabilitation case; the submission of which will occur based on the established case parameters and/or as per direction from the RS.

(1) The Closure Report is due within 5 business days of the established closure date.

(2) In addition to the elements documented in the paragraphs above, the Closure Report will require additional elements and information. These are dependent upon the status of the case at the time of closure – whether the IW has been successfully rehabilitated or if the case is being closed for other reasons.

For specific information, see Part 10 of this handbook, Case Closure.

(3) Closure of RC services requires documentation and confirmation related to the disposition of case file materials using the specific language below:

By submitting this Closure Report, I certify that I have returned to DOL/DFEC or destroyed all hard copies and electronic copies of case file information for this case and any other documents that may contain Personally Identifiable Information associated with this case, in accordance with my agreement with DOL/DFEC

Exhibits 3– 6, Closure Report Samples – provides examples of Closure Reports for various circumstances, incorporating the associated required elements.

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7. Specific Rehabilitation Reports. In addition to regular Progress Reports, the RC is required to develop and/or compile and submit a variety of other formal reports throughout the rehabilitation process. The timelines, content and required elements for these reports are discussed in other Parts of this handbook:

(1) Rehabilitation Plan – See Part 8 of this handbook, Plan Development.

(2) Individual Rehabilitation Placement Plan – See Part 8 of this handbook, Plan Development.

(3) Vocational Evaluation Report – See Part 6 of this handbook, Vocational Rehabilitation Services.

(4) Transferrable Skills Analysis – See Part 6 of this handbook, Vocational Rehabilitation Services.

(5) Labor Market Survey, See Part 8 of this handbook, Plan Development.

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Exhibit 1: Monthly Progress Report Sample

Rehabilitation Progress Report

Claimant Name:

Case File Number:

Date of Report:

Dates of Service: {from – to}

RC Name:

Contact Number:

Email Address:

Current Rehabilitation Status

Status Expires

Rehabilitation Costs

$_____FOR CURRENT STATUS $_____TOTAL COSTS TO DATE

Professional and Non-Professional Hours

______FOR CURRENT STATUS _____TOTAL HOURS TO DATE (Professional)

______FOR CURRENT STATUS _____TOTAL HOURS TO DATE (Non-Professional)

For RS Attention/Action

Summary of Contacts and Activities during this Reporting Period
(Include Contacts with IW, medical or rehabilitation providers, former Federal or potential new employers, job interviews, etc; Include dates and synopsis with outcome)

RC Plan of Action for Next 30 Days
(Discuss activities and interventions planned for the next reporting period; Include recommendations and justification for any new activities or change in status, etc. that the RC feels is needed)

Probability of Success

Short and Long-Term Goals

Justification for Recommended Purchase of Equipment or Supplies

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Exhibit 2: Initial Evaluation Report Sample

Rehabilitation Initial Evaluation Report (First Progress Report)

Claimant Name:

Case File Number:

Date of Report:

Dates of Service: {from – to}

RC Name:

Contact Number:

Email Address:

Current Rehabilitation Status

Status Expires

Rehabilitation Costs

$_____FOR CURRENT STATUS $_____TOTAL COSTS TO DATE

Professional and Non-Professional Hours

______FOR CURRENT STATUS _____TOTAL HOURS TO DATE (Professional)

______FOR CURRENT STATUS _____TOTAL HOURS TO DATE (Non-Professional)

For RS Attention/Action

Injured Worker Assessment

1. General personal background information:

2. Medical history related to work injury:

3. Date of Injury Position Information (description of duties, regular work schedule, how long in this position, etc.):

4. Employment and education background: (Prior work and educational history; potential transferrable skills, etc.):

5. IW goals related to return to work:

6. Potential barriers to return to work efforts: {ex: home environment, transportation, etc.}

Medical Information

7. Work Restrictions on file:

Restrictions documented/date:

Other medical issues or questions (explain):

Employing Agency Information and Contacts

8. EA information:
(Include the information related to each person you may have had contact with during the reporting period.)

Name of contact:

Contact number:

Position: {Injury Compensation Specialist, Duty station supervisor}

Date of contact:

8a. Date of Injury (DOI) position description obtained: Y___ N___

8b. Agency is able to provide light duty: Y___ N___

8c. Job offer requested: Y___ N___ Date:

8d. Job offer obtained and submitted for file: Y___ N ___ Date:

Summary of Contacts and Activities during this Reporting Period
(Include contacts with IW, medical or rehabilitation providers, former Federal or potential new employers, job interviews, etc; Include dates and synopsis with outcome)

Probability of Success

Short and Long-Term Goals

Justification for Recommended Purchase of Equipment or Supplies

Invoice for RC Services Attached

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Exhibit 3: Closure Report Sample

Rehabilitation Closure Report- Employed, Previous Federal Employer (PPE)

Claimant Name:

Case File Number:

Date of Report:

Dates of Service: {from – to}

RC Name:

Contact Number:

Email Address:

Date of Case Closure (as directed by RS):

Current Employment Status

(1) Working for Previous Federal Employer? Y____ N_____

(2) Dates of Employment (Date Employment Began – date of report) _______-_______

(3) Employment consistent for 60 or more days? Y____ N______

(4) Current work status confirmed on: (Date) _______________

(5) Work status and hours confirmed by: ___________________
(name of Employing Agency representative)

(6) Employment information:

a. Name and address of the employer

b. Position title

c. Date of employment

d. Schedule/hours

e. Wages/salary and Grade/step

f. Name and job title of supervisor or contact-person providing the information

g. Provided to the RS –

- Copy of job offer from Federal employer, including the IW's
signed acceptance Y______ N______

- Copy of the position description Y_____ N_____

RC's Statement of Medical and Vocational Suitability of Position:
(Include information about accommodations to be provided on the job, if needed)

Rehabilitation Costs

$_____FOR CURRENT STATUS $_____TOTAL COSTS TO DATE

Professional and Non-Professional Hours

______FOR CURRENT STATUS _____TOTAL HOURS TO DATE (Professional)

______FOR CURRENT STATUS _____TOTAL HOURS TO DATE (Non-Professional)

For RS Attention/Action

Summary of Substantial Services Provided throughout Rehabilitation Case:

Post-Employment Services Required? Y_____ N_____
(If yes, discuss type and length of services needed and provide justification)

Final Invoice for RC Services Attached

By submitting this Closure Report, I certify that I have returned to the DOL/DFEC or destroyed all hard copies and electronic copies of case file information for this case and any other documents that may contain Personally Identifiable Information associated with this case, in accordance with my agreement with the DOL/DFEC.

___ All records destroyed by RC.

___ All records returned to DFEC via traceable route.

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Exhibit 4: Closure Report Sample

Rehabilitation Closure Report- Employed, New Employer (PNE)

Claimant Name:

Case File Number:

Date of Report:

Dates of Service: {from – to}

RC Name:

Contact Number:

Email Address:

Date of Case Closure (as directed by RS):

Current Employment Status

(1) Working for New Employer? Y____ N_____

(2) Dates of Employment (Date Employment Began – date of report) _______-_______

(3) Employment consistent for 60 or more days? Y____ N______

(4) Current work status confirmed on: (Date) _______________

(5) Work status and hours confirmed by: ___________________
(name of Employing Agency representative)

(6) Employment information:

a. Name and address of the employer

b. Position title

c. DOT Code which most closely matches position

d. Date of employment

e. Schedule/hours

f. Wages/salary and Grade/step (if applicable)

g. Name and job title of supervisor or contact-person providing the information

h. Copy of Position Description provided to the RS? Y____ N_____

(7) Assisted Reemployment Initiative utilized? Y_____ N_____

If so, provided to the RS:

(a) The Cooperative Agreement authorized by the District Director ____

(b) The rate and length of continued wage reimbursement ____

RC's Statement of Medical and Vocational Suitability, and Reasonable Availability of Position: (Include information about accommodations to be provided on the job, if needed)

Rehabilitation Costs

$_____FOR CURRENT STATUS $_____TOTAL COSTS TO DATE

Professional and Non-Professional Hours

______FOR CURRENT STATUS _____TOTAL HOURS TO DATE (Professional)

______FOR CURRENT STATUS _____TOTAL HOURS TO DATE (Non-Professional)

For RS Attention/Action

Summary of Substantial Services Provided throughout Rehabilitation Case:

Post-Employment Services Required? Y_____ N_____
(If yes, discuss type and length of services needed and provide justification)

Final Invoice for RC Services Attached

___ All records destroyed by RC.

___ All records returned to DFEC via traceable route.

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Exhibit 5: Closure Report, Wage-Earning Capacity Data Included

Rehabilitation Closure Report, Wage-Earning Capacity Data Included

Claimant Name:

Case File Number:

Date of Report:

Dates of Service: {from – to}

RC Name:

Contact Number:

Email Address:

Reason for Closure:

___ PNE Status Expired, No Return to Work

___ Training or Educational Program Not Completed

___ Other

___ Closed per instruction of CE

Current Rehabilitation Status

Rehabilitation Costs

$_____FOR CURRENT STATUS $_____TOTAL COSTS TO DATE

Professional and Non-Professional Hours

______FOR CURRENT STATUS _____TOTAL HOURS TO DATE (Professional)

______FOR CURRENT STATUS _____TOTAL HOURS TO DATE (Non-Professional)

For RS Attention/Action

Summary of Number and Types of Job Contacts Made and Job Leads Forwarded to IW during PNE Process (can be listed here or attached to Closure Report)

RC's Assessment Regarding why Training, Placement or other Applicable Rehabilitation Services were not Successful (include RC's opinion and also any additional information on things which may have impacted return to work efforts)

Wage-Earning Capacity Information:

(1) Two (or three) target job titles, with DOT codes, which are medically and vocationally suitable (confirm the continued suitability of original target positions or choose new positions, as appropriate)

a. Job Title_______________,DOT Code_____

b. Job Title_______________,DOT Code_____

(2) Discuss why/how each of these positions is medically and vocationally suitable based on the IW's work restrictions, vocational skills, history and experience, including how SVP is met

(3) Labor Market information updated or reconfirmed as needed for each job title

a. Is Labor Market Survey information and data on the current Job Classification Forms, OWCP-66, sufficiently current and still appropriate, as per discussion with RS? Y____ N_____

(i) If Yes, reconfirm that jobs still exist in IW's commuting area in reasonable numbers and provide statement here. Include entry level prevailing wage data.

(ii) If No, because LMS data is not sufficiently current, or new job titles are used, perform new Labor Market Surveys on each target job title and gather information regarding availability and prevailing wage. Provide this information on new Job Classification Forms, OWCP-66, and with accompanying LMS documentation.

(iii) If the IW can qualify for more than entry level salary, explain the reasons why here or on Form OWCP-66, as appropriate

Final Invoice for RC Services Attached

Disposition of Case File Records and Materials:

___ All records destroyed by RC.

___ All records returned to DFEC via traceable route.

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Exhibit 6: Closure Report, Other

Rehabilitation Closure Report- Other

Claimant Name:

Case File Number:

Date of Report:

Dates of Service: {from – to}

RC Name:

Contact Number:

Email Address:

Reason for Closure:

_____ Medically Not Feasible

_____ Non-Cooperation or Inability to Contact

_____ Other

Closure Authorized by RS? Y____ N_____

Current Rehabilitation Status

Rehabilitation Costs

$_____FOR CURRENT STATUS $_____TOTAL COSTS TO DATE

Professional and Non-Professional Hours

______FOR CURRENT STATUS _____TOTAL HOURS TO DATE (Professional)

______FOR CURRENT STATUS _____TOTAL HOURS TO DATE (Non-Professional)

For RS Attention/Action

RC Assessment of Interventions and Activities Performed during this Reporting Period
(Include a review of planned goals and objectives, advise if they were met; if not met, what prevented them from being met; Discuss barriers and interventions including medical issues or issues of non-cooperation which impacted return to work efforts. Explain RC's interventions and attempts to facilitate services)

Final Invoice for RC Services Attached

Disposition of Case File Records and Materials:

___ All records destroyed by RC.

___ All records returned to DFEC via traceable route.

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