CCLME.ORG - DIVISION 1. DEPARTMENT OF INDUSTRIAL RELATIONS CHAPTERS 1 through 6

(continued)
You can contact the Rehabilitation Unit by phone, or you may request assistance by completing aRequest for Dispute Resolution(DWC Form RU-103).
There is also a toll-free information number you may call for a recorded message - 1-800-736-7401. You may also request any forms or printed information that you may need by calling the toll-free number.
Should I have an attorney represent me? How much will it cost?

Both the DWC rehabilitation consultant and the information and assistance officer are available to help at no cost to you.
If you decide you want the services of an attorney, you will be represented on matters involving your workers' compensation claim(s). Your attorney will represent you before the Workers' Compensation Appeals Board and Rehabilitation Unit. Your attorney will also represent you in any proceedings before any appellate court, or any proceedings designed to execute on an award.
You should be aware that your weekly vocational rehabilitation maintenance allowance payment (VRMA) may be reduced to pay the attorney. Generally 12% of your weekly VRMA is set aside for payment of attorney fees. For example, if you are entitled to the maximum rate of $246 per week, a 12% reduction means that you would receive $216.48 per week For this reason, you should discuss attorney's fees with the attorney.
You may or may not be entitled to otherrights.

The federal Americans with Disabilities Act (ADA) prohibits discrimination against qualified individuals. Qualified individuals include persons who have a physical or mental impairment that substantially limits one or more life activities and who can perform essential job functions. The employer is required to provide a reasonable accommodation if it would not impose an "undue hardship" on the employer.
For information on the Americans with Disabilities Act, call the Equal Employment Opportunity Commission at 1-800-USA-EEOC.
The state Department of Fair Employment and Housing (FEHA) administers California laws that prohibit harassment or discrimination in employment, housing and public accommodations. If you feel an employer has discriminated against you and you want information, the phone number is 1-800-884-1684.
Here is how to get helpful information:

This publication is intended to answer the most frequently asked questions. It may not necessarily provide a solution for your particular problem, because the specific facts of your situation may call for a different approach. The information contained here is general in nature, and not intended as a substitute for legal advice.
If you have more questions after reading this publication, contact one of the DWC Information and Assistance offices or Rehabilitation offices listed in the white pages of your telephone directory under "State Government Offices, Department of Industrial Relations" or contact the web site at: www.dir.ca.gov.
ANYONE WHO KNOWINGLY FILES OR ASSISTS IN THE FILING OF A FALSE WORKERS' COMPENSATION CLAIM MAY BE FINED UP TO $50,000 AND SENT TO PRISON FOR UP TO FIVE YEARS.
[Insurance Code Section 1871.4]

State of California Department of Industrial Relations Division of Workers' Compensation Rehabilitation Unit

Note: Authority cited: Sections 133, 139.5, 139.6 and 5307.3, Labor Code. Reference: Sections 139.5, 4636 and 4646, Labor Code.

s 10133.3. Rehabilitation Unit File Retention.
(a) The unit shall retain its files until 90 days from the date of the filing of the "Notice of Termination of Rehabilitation Services", DWC RU 105, unless a timely objection to the notice is filed by the employee. File retention shall be extended to 90 days beyond a final decision of the appeals board on a petition which appeals a unit finding, decision or determination. If no activity on a file is reported to the Rehabilitation Unit for more than 18 months, the Unit shall not retain its file.
(b) When the parties, subsequent to the time limits in subsection (a), request a determination by the unit, the unit may require the parties to provide copies of pertinent notices, reports and documents which are necessary for the unit to make its determination.

Note: Authority cited: Sections 133, 138.4, 139.5 and 5307.3, Labor Code. Reference: Section 139.5, Labor Code..

s 10133.4. Rehabilitation of Industrially Injured Inmates.
(a) Inmates of a state penal or correctional institution may be eligible for workers' compensation benefits, including the provision of vocational rehabilitation services, for injuries which occur during their incarceration and while engaged in assigned work or employment. As used in this section:
(1) "Assigned work or employment" means work performed in any pay or non-pay position in a work program under the direction and with the approval of a duly authorized inmate leadman or supervisory leadman or Department of Corrections employee. The term does not include skill centers, vocational training or academic education programs (except for physical fitness training and forestry training which are authorized by Labor Code Section 3365 as prerequisites to fire suppression duties) or activities which are clearly not encompassed within the duties and responsibilities of the position to which assigned.
(2) "Inmate of a state penal or correctional institution" means a person committed to the custody of the Department of Corrections; and who is in a facility, camp, hospital, or institution of the Department of Corrections for the purpose of confinement, treatment, employment, training, or discipline; or who has been temporarily removed by the Department of Corrections from a facility under its jurisdiction with or without custody, for the performance of assigned work. The term does not include a prisoner who has escaped or who has been released on parole.
(3) "Director," as cited in subdivision (b) of Section 5069 of the Penal Code, means the Director of Corrections. In addition to the requirements of Sections 10123, 10124 and 10126, the Director of Corrections shall provide notice of the availability of vocational rehabilitation services to inmates disabled for 28 calendar days or more, on a form prescribed by the director. A copy of such form shall be sent to the Department of Rehabilitation.
(b) Notwithstanding Section 10125.1, an injured inmate who otherwise qualifies for vocational rehabilitation services shall not be entitled to vocational rehabilitation maintenance allowance payments while serving in a state penal or correctional institution.
(c) Vocational rehabilitation services to determine an inmate's eligibility as a qualified injured worker, and to develop any required vocational rehabilitation plan, shall be provided by a rehabilitation representative chosen by the Department of Corrections. Such services shall be provided the inmate as soon as it is feasible and prior to the inmate's release from custody, if possible, with the intent of preparing the inmate for suitable gainful employment upon release. Nothing shall bar the development and implementation of a plan, however, prior to the inmate's release, using modified work or an otherwise suitable work position meeting the definition of assigned work or employment under subsection (a) of this section.

Note: Authority cited: Sections 133, 138.4, 139.5 and 5307.3, Labor Code. Reference: Sections 3351 and 3370, Labor Code; and Section 5069, Penal Code.

s 10133.10. Form RU-90 "Treating Physician's Report of Disability Status" and Form Filing Instructions.

Rehabilitation Unit California Division of Workers' Compensation Form RU-90
TREATING PHYSICIAN'S REPORT OF DISABILITY STATUS

Purpose: To allow early identification of employee's potential need for vocational rehabilitation services, the claims administrator or Qualified Rehabilitation Representative must solicit the treating physician's opinion concerning the employee's ability to return to previous employment.
Submitted by: Qualified Rehabilitation Representative assigned by claims administrator, if the injury is before 1/1/94 or claims administrator if the injury is on or after 1/1/94.
When submitted: At 90 days of aggregate temporary disability and thereafter at 60 day intervals, or less, until medical eligibility has been determined.
Where submitted: To the treating physician.Do not file the RU-90 or RU-91 with the Rehabilitation Unit unless specifically requested or when submitting information as part of a dispute.
Form completion: The Qualified Rehabilitation Representative or claims administrator completes the identification data on the form and the treating physician is responsible for the completion of the remainder of the form, including signature.Be sure to fill in the claims administrator name and address or the doctor may become confused and return the form to the Rehabilitation Unit.Upon completion, the treating physician returns the form to the claims administrator with a copy to the Qualified Rehabilitation Representative, if applicable, and injured worker. Accompanying document: Description of Employee's Job Duties (RU-91) must be included when the RU-90 is initially sent to the treating physician. Response to RU-90: The claims administrator within 10 days of receipt of the final Treating Physician's Report Of Disability Status (RU-90), shall notify the employee of his/her status using the prescribed Notice of Potential Eligibility or Denial of Vocational Rehabilitation Services, whichever is applicable. The completed RU-90 is a medical report and is to be served on all parties by the claims administrator with the previously completed RU-91. Rehabilitation Unit action: None.

Note: Authority cited: Sections 133, 139.5 and 5307.3, Labor Code. Reference: Sections 4636 and 4637, Labor Code.

s 10133.11. Form RU-91 "Description of Employee's Job Duties" and Form Filing Instructions.

Rehabilitation Unit California Division of Workers' Compensation Form RU-91
DESCRIPTION OF EMPLOYEE'S JOB DUTIES

Purpose: To obtain a job description which is to be forwarded to the employee's treating physician when an injury or illness results in disability exceeding 90 days.
Submitted by:
1. Qualified Rehabilitation Representative, if the injury is before 1/1/94, or
2. Claims Administrator if the injury is on or after 1/1/94.
When prepared: If the injury is before 1/1/94, the QRR meets with the employee to jointly complete this form and provides a copy of the form in conjunction with the RU-90 to the employee's treating physician. If the injury is on or after 1/1/94, the claims administrator consults with the injured worker in completing the RU-91 and then submits it to the treating physician.
When submitted: To the treating physician.Do not file the RU-90 or RU-91 with the Rehabilitation Unit unless specifically requested or when submitting information as part of a dispute.
Form completion: Qualified Rehabilitation Representative or claim administrator, in consultation with the employee and employer, completes the entire form.
Accompanying document: The RU-91 is to be attached to the RU-90 and submitted to the treating doctor.
Rehabilitation Unit action: None.

Note: Authority cited: Sections 133, 139.5 and 5307.3, Labor Code. Reference: Sections 4636 and 4637, Labor Code.

s 10133.12. Form RU-94 "Notice of Offer of Modified or Alternative Work" and Form Filing Instructions.

Rehabilitation Unit California Division of Workers' Compensation Form RU-94
NOTICE OF OFFER OF MODIFIED OR ALTERNATIVE WORK

Purpose: To document an offer of modified or alternative work by the employer at the time of injury. The form also documents the acceptance or rejection of modified or alternate work by the injured employee. The RU-94 is to be used only for injuries which occur on or after 1-1-94.
Submitted by: The claims administrator obtains the response of the injured worker and submits the form to the Rehabilitation Unit.
When prepared: The form is prepared at the time of the offer of modified or alternative work by the employer or claims administrator. This form is not to be used to document a plan for modified or alternate work offered subsequent to advising the worker that modified or alternative work wasnotavailable.
Where submitted: Initially to the injured worker within 30 days of the acceptance or rejection of the offer, then it is submitted to the Rehabilitation Unit, together with a RU-105.
Form completion: The employer or claims administrator completes the information in the top box. The employee completes the section so marked.
Accompanying document: The RU-94 is submitted with a RU-105 Notice of Termination. The submitted RU-94 must also include a list of duties required of the position and wages offered.
Rehabilitation Unit action: The Rehabilitation Unit will not take action unless the employee objects by filing a RU-103, Request for Dispute Resolution, to the Notice of Termination.
Note: If the offer is not accepted or rejected within 30 days of the offer, the offer is deemed to be rejected by the employee. The employer has the option to file a RU-105, Notice of Termination, or extend the 30-day period by mutual agreement.

Note: Authority cited: Sections 133, 139.5 and 5307.3, Labor Code. Reference: Sections 4636 and 4637, Labor Code.

s 10133.13. Form RU-102 "Vocational Rehabilitation Plan" and Form Filing Instructions.

Rehabilitation Unit California Division of Workers' Compensation Form RU-102
VOCATIONAL REHABILITATION PLAN* PLANS FOR REPRESENTED EMPLOYEES INJURED ON OR
AFTER 1/1/94

Purpose: To document objectives and methods to be used to implement a proposed rehabilitation plan.
Submitted by: Claims Administrator
When submitted: The Claims Administrator submits the form with a RU-105 at the completion of the plan.
Where submitted: With the applicable Rehabilitation Unit district office. The Rehabilitation Unit's venue is the same as the WCAB. If no WCAB case exists, file with a Rehabilitation Unit within the county where the injured employee resides.
Form completion: See the following page for information on properly completing the form.
Please note: This form must be completed using type no smaller than 10 point. All information must be contained within the section provided.
Accompanying documents: Within 10 days of plan completion, submit the RU-102 along with a RU-105 Notice of Termination.Medical and vocational reports should not be attached.
Rehabilitation Unit action: Statistical recording.
Copy: All parties
PLANS FOR UNREPRESENTED EMPLOYEE OR WITH A QRR WAIVER AND ALL PLANS FOR
EMPLOYEES INJURED BEFORE 1/1/94

Purpose: To document objectives and methods to be used to implement a proposed rehabilitation plan.
Submitted by: Claims Administrator
When submitted: Immediately upon development of a rehabilitation plan which has been agreed to by the parties. If a waiver of Qualified Rehabilitation Representative is requested,whether represented or not,the plan must be submitted for approval.
Where submitted: With the applicable Rehabilitation Unit district office. The Rehabilitation Unit's venue is the same as the WCAB's. If no WCAB case exists, file with a Rehabilitation Unit within the county where the injured employee resides.
Form completion: See the following page for information on properly completing the form.
Please note: This form must be completed using type no smaller than 10 point. All information must be contained within the section provided.
Accompanying documents: Include all supporting medical and vocational reports not previously submitted.
Rehabilitation Unit action: If disapproval is not made within 30 days of a properly documented plan, the plan is deemed approved. A notice of approval will issue in instances where disapproval previously issued.
Copy: All parties.
INFORMATION ON HOW TO PROPERLY COMPLETE THE FORM RU-102

Form completion: Submit only if the employee is a Qualified Injured Worker. The RU-102 is prepared by a Qualified Rehabilitation Representative (QRR). In filing out the form, avoid continuation of information to additional sheets. An extension of the information requested on the RU-102 to additional sheets should be limited to only the situation where there is an OJT agreement which describes the responsibilities of the parties and details of training.
Page 1; The QRR completes the required information. The box in the lower left hand corner are for the parties to initial to show their agreement with the plan. Employee level of participation must be described.
Page 2: The QRR completes the information and the parties initial the page. The RU-102 is used for modified or alternative work plans when the offer of modified or alternate work is made subsequent to the initiation of rehab services. The box in the lower left hand corner is for the parties to initial to show agreement. If training, education, or tutoring is a part of the plan, the counselor must select a facility or program approved by the council for Private Post Secondary and Vocational Education.
Page 3: For injuries before 1/1/94--This page describes expected costs of the plan. There is not a legislatively required limit of $16,000 on total costs.
For injuries on or after 1/1/94--The purpose of the budget is to plan the estimated expenditures. The total budget for rehabilitation services may not exceed $16,000 including QRR fees. For QRR's fees, please refer to the fee schedule in the administrative rules.
This page may be helpful as a counseling tool to show the injured worker that greater expenditures in one area must be balanced with savings in others areas or the development of additional monetary resources.
Description of specific items on Page 3
VRMA/VRTD to date- refers to the rate and sum of VRMA payments made since the claims administrator sent the notice of potential eligibility and the injured worker requested rehabilitation services.
VRMA/VRTD to be paid- refers to the rate and sum of VRMA payments during the plan.
If the claims administrator is withholding for attorney fees, the should be calculated along with the actual weekly benefit payment so the worker will know how much he or she actually receives.
Any allocation forTRANSPORTATION EXPENSESsuch as gas money or public transit tickets must be calculated.
AnyTRAINING/TUITION FEESand the training provider must be listed.
OTHER COSTS- such as clothing, tools, books, babysitting, relocation costs, or any other plan costs not itemized above on the form should be listed.
FEES FOR EVALUATION, PLAN DEVELOPMENT AND PLACEMENTand other expenditures from the fee schedule must be listed.
To insure that total plan costs do not exceed $16,000 add the following:
1) VRMA/VRTD paid to date -- total
2) VRMA/VRTD to be paid -- total
3) Transportation expenses -- total
4) Total of plan expenditures
5) Total of fees for evaluation, plan development, and placement
The injured worker must insure that he can meet his living expenses during the plan by adding the total weekly benefit payment to employee to the permanent disability supplement to be paid and any other confirmed financial resources which are listed. In addition, the injured worker can calculate expenditures for legal and rehabilitation fees by adding the total of amount withheld for attorney fees and the total of fees for evaluation, plan development and placement.
Regarding section C-2, labor market surveys are not required. Labor market assessment should include information from the California Occupational Information System if it is available.
The box in the lower left hand corner is for the parties to initial to show agreements.
Page 4: This is the signature page.
Please note: The claims administrator is expected to sign space in Section D as well as Section F.
Please note: Any plan, whether the employee is represented or not, which provides funds to the employee to be disbursed at the employee's discretion or on a non-specific basis must be submitted for review to the Rehabilitation Unit to determine whether the plan is in conflict with Labor Code Section 4646 as required by AD 10126(b)(4).

Note: Authority cited: Sections 133, 139.5 and 5307.3, Labor Code. Reference: Sections 4635, 4636 and 4638, Labor Code.

s 10133.14. Form RU-103 "Request for Dispute Resolution" and Form Filing Instructions.

Rehabilitation Unit California Division of Workers' Compensation Form RU-103
REQUEST FOR DISPUTE RESOLUTION

Purpose: To request the Rehabilitation Unit to resolve a disputed rehabilitation issue.
Submitted by: Any party of interest.
When submitted: The form should only be submitted after all informal methods to resolve the rehabilitation dispute have been exhausted or in response to a RU-103 filed by the other party, or in response to a RU-105 Notice with which the employee disagrees.
Where submitted: With the applicable Rehabilitation Unit district office. The Rehabilitation Unit's venue is the same as the WCAB's. If no WCAB case exists, file with a Rehabilitation Unit within the county where the injured employee resides.
Form completion: This form will be returned or the request denied if:
r Liability for injury is in dispute. r The form is incomplete. r The requester has not attempted to resolve the dispute or such attempts have not been thoroughly documented on the form. r Copies of all medical and vocational reports not previously filed are not attached.
Accompanying document: Attach all medical and vocational reports not previously filed.
Response to RU-103: The other parties shall have fifteen (15) days to respond by forwarding their position via a RU-103, with supporting information, to the correct Rehabilitation Unit District office with copies to all parties.
Rehabilitation Unit action: The Rehabilitation Unit shall either issue a determination based on the record, request additional information, or set the matter for formal conference.
Copy: All parties.
Please note: An expedited dispute resolution conference is to resolve a single issue as identified on the RU-103. If other issues are raised, a subsequent conference will be scheduled or a determination will be issued on the record.

Note: Authority cited: Sections 133, 139.5 and 5307.3, Labor Code. Reference: Section 4638, Labor Code.

s 10133.15. Form RB-105 "Request for Conclusion of Rehabilitation Benefits" and Form Filing Instructions.

DWC Form RU-105 (5/03)

DWC Form RU-105 (5/03)
Rehabilitation Unit California Division of Workers' Compensation Form RB-105
REQUEST FOR CONCLUSION OF REHABILITATION BENEFITS

Purpose: To request the Rehabilitation Unit's approval of conclusion of rehabilitation services for injuries before 1-1-90. For injuries on or after 1- 1-90, use the Notice of Termination of Rehabilitation Services (RU-105).
Submitted by: Claims Administrator.
When submitted: Within ten (10) days of the circumstances as described on the form.
Where submitted: To the applicable Rehabilitation Unit district office. The Rehabilitation Unit's venue is the same as the WCAB's. If no WCAB case exists, file with a Rehabilitation Unit within the county where the injured employee resides.
Form completion: Please note this form will be returned or the request denied if:
r The box was not checked for the reason of the request. r The request lacks substantiation as required. r Copies have not been sent to the employee and his/her representative, if represented. r The copy of service section is incomplete.
Accompanying documents: Relevant medical and vocational reports.
Rehabilitation Unit action: When the employee objects to the RB-105, the rehabilitation unit will hold a conference or otherwise obtain the reason for objection and issue its decision. If the employee objects, a RU-103 (Request For Dispute Resolution) must be filed. Check the box "the requesting party objects to the request for termination or conclusion of vocational rehabilitation benefits"and provide the reasons for the objection.
Copy: All parties.

Note: Authority cited: Sections 133, 139.5 and 5307.3, Labor Code. Reference: Sections 4637, 4643 and 4644, Labor Code.

s 10133.16. Form RU-105 "Notice of Termination of Vocational Rehabilitation Services" and Form Filing Instructions.

Rehabilitation Unit California Division of Workers' Compensation RU-105 NOTICE
OF TERMINATION OF REHABILITATION SERVICES

Purpose: To notify the employee of the employer's termination of liability to provide rehabilitation services. It is not to be used for non-feasibility. This notice is not to be used for injuries prior to 1990.
Submitted by: Claims Administrator to the injured employee and representative.
When submitted: Within 10 days of the circumstances set forth in LC s4644(a).
Where submitted: Original of the notice is sent to the employee and a copy to the applicable Rehabilitation Unit district office. The Rehabilitation Unit's venue is the same as the WCAB. If no WCAB case exists, file with a Rehabilitation Unit within the county where the injured employee resides.
Accompanying documents:
r RU-94 for DOI's on or after 1/1/94 where an offer of modified or alternate work has been accepted or rejected. r Agreed upon plans for represented injured workers whose date of injury is on or after 1/1/94. (See 1994-1999 rules - AR 10126b(3)) r All declination forms andNotice of Potential Eligibility. r A copy of proof of service.
Rehabilitation Unit action: When the employee objects to the notice of termination, the Rehabilitation Unit will hold a conference or otherwise obtain the employee's reason for objection and issue its decision.
Notes: Copies of medical or vocational reports are not required to be submitted to the Rehabilitation Unit when filing a copy of the RU-105 on injuries subsequent to 1/1/90. All RU-105 Notices must have a "Proof of Service" as required by AR 10131(a). For further information of "Proof of Service" see 8 Cal 10514.

Note: Authority cited: Sections 133, 139.5 and 5307.3, Labor Code. Reference: Sections 4637 and 4644, Labor Code.

s 10133.17. Form RB-107 "Statement of Decline of Vocational Rehabilitation Benefits" and Form Filing Instructions.

Rehabilitation Unit California Division of Workers' Compensation Form RB-107
STATEMENT OF DECLINE OF VOCATIONAL REHABILITATION BENEFITS

Purpose: To record the employee's declination of rehabilitation services for injuries before 1/1/90.
Submitted by: Claims Administrator
When submitted: When the employee chooses to decline Vocational Rehabilitation Services.
Where submitted: With the RB-105 to the applicable office of the Rehabilitation Unit
Form completion: Identifying data completed by Claims Administrator. Statement of employee completed by injured worker with signature of injured worker and attorney, if represented.
Accompanying documents: Request for Conclusion Form RB-105
Response to RU-103: The other parties shall have twenty (20) days to respond by forwarding their position, with supporting information, to the applicable Rehabilitation Unit district office with copies to all parties.
Rehabilitation Unit action: If the employee objects to the Request for Conclusion, the Rehabilitation Unit shall, within 30 days, schedule a conference or otherwise obtain the employee's reason for objection with substantiating evidence and issue its determination.
Copy: All parties.

Note: Authority cited: Sections 133, 139.5 and 5307.3, Labor Code. Reference: Sections 4641 and 4644, Labor Code.

s 10133.18. Form RU-107 "Employee Statement of Declination of Vocational Rehabilitation Services" and Form Filing Instructions.

Rehabilitation Unit California Division of Workers' Compensation Form RU-107
EMPLOYEE STATEMENT OF DECLINATION OF VOCATIONAL REHABILITATION SERVICES

Purpose: To record the employee's declination of rehabilitation services for injuries between 1/1/90 and 12/31/93, inclusive.
Submitted by: Claims Administrator.
When submitted: When the employee chooses to decline vocational rehabilitation services.
Where submitted: With the RU-105 to the applicable Rehabilitation Unit district office
Form completion: Identifying data completed by Claims Administrator Signature of employee and attorney, if represented.
Accompanying documents: Notice of Termination of Rehabilitation Services RU-105; A copy of theNotice of Potential Eligibility; Verification of the 90 day explanation of rights by a QRR;
Response to the RU-103: The other parties shall have twenty (20) days to respond by forwarding their position, with supporting information, to the applicable Rehabilitation Unit district office with copies to all parties.
Rehabilitation Unit action: If the employee objects to the employer's Notice of Termination, the Rehabilitation Unit shall, within 30 days, schedule a conference or otherwise obtain the employee's reason for objection together with substantiating evidence and issue its decision.
Copy: All parties.

Note: Authority cited: Sections 133, 139.5 and 5307.3, Labor Code. Reference: Sections 4641 and 4644, Labor Code.

s 10133.19. Form RU-107A "Statement of Declination of Vocational Rehabilitation Services" and Form Filing Instructions.

Rehabilitation Unit California Division of Workers' Compensation Form RU-107A
EMPLOYEE STATEMENT OF DECLINATION OF VOCATIONAL REHABILITATION SERVICES

Purpose: To record the employee's declination of rehabilitation services for injuries on or after 1/1/94.
Submitted by: Claims Administrator
When submitted: When the employee chooses to decline vocational rehabilitation services.
Where submitted: With the RU-105 to the applicable Rehabilitation Unit district office
Form completion: Identifying data completed by Claims Administrator; signature of employee and attorney, if represented.
Accompanying documents: Notice of Termination of Rehabilitation Services (RU-105) A copy of theNotice of Potential Eligibility.
Rehabilitation Unit action: If the employee objects to the Notice of Termination, the Rehabilitation Unit shall, within 30 days, schedule a conference or otherwise obtain the employee's reason for objection together with substantiating evidence and issue its decision.
Copy: All parties.

Note: Authority cited: Sections 133, 139.5 and 5307.3, Labor Code. Reference: Sections 4641 and 4644, Labor Code.

s 10133.20. Form RU-120 "Initial Evaluation Summary" and Form Filing Instructions.

Rehabilitation Unit California Division of Workers' Compensation Form RU-120
INITIAL EVALUATION SUMMARY

Purpose: To document the findings and recommendations of the Qualified Rehabilitation Representative who conducts the initial evaluation. Per AR s10132.1, such assessment is to include an initial assessment of the worker's ability to benefit from VR services.
Submitted by: Qualified Rehabilitation Representative (QRR).
When submitted: The Rehabilitation Unit encourages an expeditious assessment of employee skills and vocational feasibility. The RU-120 should be submitted not later than 30 days from completion of the initial interview unless otherwise agreed to.
Where submitted: To the claims administrator with copies to all parties. If the QRR is functioning as an Independent Vocational Evaluator (IVE), the RU-120 would be filed directly with the Rehabilitation Unit with copies to all parties.
Form completion: This form is to be completed by the QRR. The purpose of the form is to obtain comprehensive, yet concise, information which is critical for assessing vocational feasibility and developing an appropriate plan per the California Standards Governing Timeliness and Quality of Vocational Rehabilitation Services. Information gathered for each section must fit within the section designated for that category and the typeface must be no smaller than 10 point. The cost of additional or more detailed reports shall be borne by the party requesting them.
Accompanying documents: None
Rehabilitation Unit action: None.
Copy: All parties.

Note: Authority cited: Sections 133, 138.4, 139.5 and 5307.3, Labor Code. Reference: Section 139.5, Labor Code.

s 10133.21. Form RU-121 "Vocational Rehabilitation Progress Report" and Form Filing Instructions.

Rehabilitation Unit California Division of Workers' Compensation Form RU-121
VOCATIONAL REHABILITATION PROGRESS REPORT

Purpose: To report on the progress of the employee who is receiving vocational rehabilitation services.
Submitted by: Qualified Rehabilitation Representative (QRR)
When submitted: Reports are done no less often than once per month unless otherwise agreed to, due to cap considerations. The QRR shall report to all parties within 10 days of the completion of services.
Where submitted: To the claims administrator with copies to all parties. If the QRR is functioning as an Independent Vocational Evaluator, the RU-121 would be filed directly with the Rehabilitation Unit with copies to all parties.
Form completion: This form is to be completed by the QRR. The purpose of the form is to obtain comprehensive, yet concise, information on the progress of vocational services. The information gathered for each section must fit within the section designated for that category and the typeface must be no smaller than 10 point. The cost of additional or more detailed reports shall be borne by the party requesting them.
Accompanying documents: None
Rehabilitation Unit action: None.
Copy: All parties.

Note: Authority cited: Sections 133, 138.4, 139.5 and 5307.3, Labor Code. Reference: Section 139.5, Labor Code.

s 10133.22. Form RU-122 "Settlement of Prospective Vocational Rehabilitation Services" and Form Filing Instructions.

Rehabilitation Unit California Division of Workers' Compensation Form RU-122
SETTLEMENT OF PROSPECTIVE VOCATIONAL REHABILITATION SERVICES

Purpose: To record the agreement between the employee and the employer to settle prospective vocational rehabilitation services for injuries on or after 1/1/03.
Submitted by: Any party.
When Submitted: When the parties have agreed to settle prospective vocational rehabilitation services.
Where Submitted: To the applicable Rehabilitation Unit district office. The Rehabilitation Unit's venue is the same as the WCAB. If no WCAB case exists, file with a Rehabilitation Unit within the county where the injured employee resides.
Form Completion: Identifying data completed by claims administrator Signature of employee, employee's representative and claims administrator
Accompanying documents: None.
Rehabilitation Unit Action: The Rehabilitation Unit shall either issue a determination based on the record, request additional information, or set the matter for formal conference.
Copy: All parties

Note: Authority cited: Sections 133, 138.4, 139.5 and 5307.3, Labor Code. Reference: Sections 139.5 and 4646, Labor Code.

s 10133.50. Definitions.
(a) The following definitions apply for injuries occurring on or after January 1, 2004:
(1) Alternative Work. Work that the employee has the ability to perform, that offers wages and compensation that are at least 85 percent of those paid to the employee at the time of injury, and that is located within reasonable commuting distance of the employee's residence at the time of injury.

(2) Approved Training Facility. A training or skills enhancement facility or institution that meets the requirements of section 10133.58.
(3) Claims Administrator. The person or entity responsible for the payment of compensation for a self-administered insurer providing security for the payment of compensation required by Divisions 4 and 4.5 of the Labor Code, a self-administered self-insured employer, or a third-party claims administrator for a self-insured employer, insurer, legally uninsured employer, or joint powers authority.
(4) Employer. The person or entity that employed the injured employee at the time of injury.
(5) Essential Functions. Job duties considered crucial to the employment position held or desired by the employee. Functions may be considered essential because the position exists to perform the function, the function requires specialized expertise, serious results may occur if the function is not performed, other employees are not available to perform the function or the function occurs at peak periods and the employer cannot reorganize the work flow.

(6) Insurer. Has the same meaning as in Labor Code section 3211.
(7) Modified Work. Regular work modified so that the employee has the ability to perform all the functions of the job and that offers wages and compensation that are at least 85 percent of those paid to the employee at the time of injury, and located within a reasonable commuting distance of the employee's residence at the time of injury.
(8) Nontransferable Training Voucher. A document provided to an employee that allows the employee to enroll in education-related training or skills enhancement. The document shall include identifying information for the employee and claims administrator, specific information regarding the value of the voucher pursuant to Labor Code section 4658.5.
(9) Notice. A required letter or form generated by the claims administrator and directed to the injured employee.
(10) Offer of Modified or Alternative Work. An offer to the injured employee of medically appropriate employment with the date-of-injury employer in a form and manner prescribed by the Administrative Director.

(11) Parties. The employee, the claims administrator and their designated representatives, if any.
(12) Permanent Partial Disability Award. A final award of permanent partial disability determined by a Workers' Compensation Administrative Law Judge or the Workers' Compensation Appeals Board.
(13) Regular Work. The employee's usual occupation or the position in which the employee was engaged at the time of injury and that offers wages and compensation equivalent to those paid to the employee at the time of injury, and located within a reasonable commuting distance of the employee's residence at the time of injury.
(14) Supplemental Job Displacement Benefit. An educational retraining or skills enhancement allowance for injured employees whose employers are unable to provide work consistent with the requirements of Labor Code section 4658.6.
(15) Vocational & Return to Work Counselor (VRTWC). A person or entity capable of assisting a person with a disability with development of a return to work strategy and whose regular duties involve the evaluation, counseling and placement of disabled persons. A VRTWC must have at least an undergraduate degree in any field and three or more years full time experience in conducting vocational evaluations, counseling and placement of disabled adults.
(16) Work Restrictions. Permanent medical limitations on employment activity established by the treating physician, Qualified Medical Examiner or Agreed Medical Examiner.

Note: Authority cited: Sections 133, 4658.5 and 5307.3, Labor Code. Reference: Sections 124, 4658.1, 4658.5 and 4658.6, Labor Code.

s 10133.51. Notice of Potential Right to Supplemental Job Displacement Benefit.
(a) This section and section 10133.52 shall only apply to injuries occurring on or after January 1, 2004.
(b) Within 10 days of the last payment of temporary disability, if not previously provided, the claims administrator shall send the employee, by certified mail, the mandatory form "Notice of Potential Right to Supplemental Job Displacement Benefit Form" that is set forth in Section 10133.52.

Note: Authority cited: Sections 133, 4658.5 and 5307.3, Labor Code. Reference: Section 4658.5, Labor Code.

s 10133.52. "Notice of Potential Right to Supplemental Job Displacement Benefit Form."
Notice of Potential Right to Supplemental Job Displacement Benefit Form
(Mandatory Form)

If your injury causes permanent partial disability, which prevented you from returning to work within 60 days of the last payment of temporary disability, and the claims administrator has not provided you with a Form DWC-AD 10133.53 "Notice of Offer of Modified or Alternative Work," you may be eligible for a supplemental job displacement benefit in the form of a nontransferable voucher for education-related retraining or skill enhancement, or both, at state approved or accredited schools.
The amount of the voucher for the supplemental job displacement benefit will be as follows:
Up to four thousand dollars ($4,000) for a permanent partial disability award of less than 15%.
Up to six thousand dollars ($6,000) for a permanent partial disability award between 15 and 25%.
Up to eight thousand dollars ($8,000) for a permanent partial disability award between 26 and 49%.
Up to ten thousand dollars ($10,000) for a permanent partial disability award between 50 and 99%.
A permanent partial disability award is issued by a Workers' Compensation Administrative Law Judge or the Workers' Compensation Appeals Board. You may also settle your potential eligibility for a voucher as part of a compromise and release settlement for a lump sum payment. Any settlement must be reviewed and approved by a Workers' Compensation Administrative Law Judge.
The voucher may be used for payment of tuition, fees, books, and other expenses required by the school for retraining or skill enhancement. Not more than 10 percent of the voucher moneys may be used for vocational or return to work counseling. A list of vocational return to work counselors is available on the Division of Workers' Compensation's website www.dir.ca.gov or upon request.
If you are eligible, and you have not already settled the benefit, you will receive the voucher from the claims administrator within 25 calendar days from the date the permanent partial disability award is issued by the Workers' Compensation Administrative Law Judge or the Workers' Compensation Appeals Board.
If modified or alternative work is available, you will receive a Form DWC-AD 10133.53 "Notice of Offer of Modified or Alternative Work" from the claims administrator within 30 days of the termination of temporary disability indemnity payments. The claims administrator will not be required to pay for supplemental job displacement benefits if the offer for modified or alternative work meets the following conditions:
(1) You have the ability to perform the essential functions of the job provided;

(2) the job provided is in a regular position lasting at least 12 months;
(3) the job provided offers wages and compensation that are at least 85 percent of those paid to you at the time of the injury; and
(4) the job is located within reasonable commuting distance of your residence at the time of injury.
If there is a dispute regarding the Supplemental Job Displacement Benefit, the employee or claims administrator may file Form DWC-AD 10133.55 "Request for Dispute Resolution before the Administrative Director."
If you have a question or need more information, you can contact your employer or the claims administrator listed below. You can also contact a State Division of Workers' Compensation Information and Assistance Officer.
Date: __________ Name of Claims Administrator: __________ __________Phone No.: __________ Address of Claims Administrator: __________ __________ __________ __________ Email (optional): __________ __________ __________ __________

Note: Authority cited: Sections 133, 4658.5 and 5307.3, Labor Code. Reference: Section 4658.5, Labor Code.

s 10133.53. Form DWC-AD 10133.53 "Notice of Offer of Modified or Alternative Work."
DWC-AD 10133.53 NOTICE OF OFFER OF MODIFIED OR ALTERNATIVE WORK

For injuries occurring on or after 1/1/04

Note: Authority cited: Sections 133, 4658 and 5307.3, Labor Code. Reference: Sections 4658, 4658.1, 4658.5 and 4658.6, Labor Code.

s 10133.54. Dispute Resolution.
(a) This section and section 10133.55 shall only apply to injuries occurring on or after January 1, 2004.
(b) When there is a dispute regarding the Supplemental Job Displacement Benefit, the employee, or claims administrator may request the Administrative Director to resolve the dispute.
(c) The party requesting the Administrative Director to resolve the dispute shall:
(1) Complete Form DWC-AD 10133.55 "Request for Dispute Resolution before the Administrative Director;"
(2) Clearly state the issue(s) and identify supporting information for each issue and position;
(3) Attach all pertinent documents;
(4) Submit the original request and all attached documents to the Administrative Director and serve a copy of the request and all attached documents on all parties; and
(5) Sign and date the proof of service section of Form DWC-AD 10133.55 "Request for Dispute Resolution before the Administrative Director."
(d) The opposing party shall have twenty (20) calendar days from the date of the proof of service of the Request to submit the original response and all attached documents to the Administrative Director and serve a copy of the response and all attached documents on all parties.
(e) The Administrative Director or his or her designee may request additional information from the parties.
(f) The Administrative Director or his or her designee shall issue a written determination and order based solely on the request, response, and any attached documents within thirty (30) calendar days of the date the opposing party's response and supporting information is due. If the Administrative Director or his or her designee requests additional information, the written determination shall be issued within thirty (30) calendar days from the receipt of the additional information. In the event no decision is issued within sixty (60) calendar days of the date the opposing party's response is due or within sixty (60) calendar days of the Administrative Director's receipt of the requested additional information, whichever is later, the request shall be deemed to be denied.
(g) Either party may appeal the determination and order of the Administrative Director by filing a written petition together with a Declaration of Readiness to Proceed pursuant to section 10414 with the local district office of the Workers' Compensation Appeals Board within twenty calendar days of the issuance of the decision or within twenty days after a request is deemed denied pursuant to subdivision (f). The petition shall set forth the specific factual and/or legal reason(s) for the appeal. A copy of the petition and a copy of the Declaration of Readiness to Proceed shall be concurrently served on the Administrative Director.

Note: Authority cited: Sections 133, 4658.5 and 5307.3, Labor Code. Reference: Sections 4658.5 and 4658.6, Labor Code.

s 10133.55. Form DWC-AD 10133.55 "Request for Dispute Resolution Before the Administrative Director."
TABULAR OR GRAPHIC MATERIAL SET FORTH AT THIS POINT IS NOT DISPLAYABLE

Note: Authority cited: Sections 133, 4658.5 and 5307.3, Labor Code. Reference: Section 4658.5, Labor Code.

s 10133.56. Requirement to Issue Supplemental Job Displacement Nontransferable Training Voucher.
(a) This section and section 10133.57 shall only apply to injuries occurring on or after January 1, 2004.
(b) The employee shall be eligible for the Supplemental Job Displacement Benefit when:
(1) the injury causes permanent partial disability; and

(2) within 30 days of the termination of temporary disability indemnity payments, the claims administrator does not offer modified or alternative work in accordance with Labor Code section 4658.6; and
(3) either the injured employee does not return to work for the employer within 60 days of the termination of temporary disability benefits; or
(4) in the case of a seasonal employee, where the employee is unable to return to work within 60 days of the termination of temporary disability benefits because the work season has ended, the injured employee does not return to work on the next available work date of the next work season.
(c) When the requirements under subdivision (b) have been met, the claims administrator shall provide a nontransferable voucher for education-related retraining or skill enhancement or both to the employee within 25 calendar days from the issuance of the permanent partial disability award by the Workers' Compensation Administrative Law Judge or the Workers' Compensation Appeals Board.
(d) The voucher shall be issued to the employee allowing direct reimbursement to the employee upon the employee's presentation to the claims administrator of documentation and receipts or as a direct payment to the provider of the education related training or skill enhancement and/or to the VRTWC.
(e) The voucher must indicate the appropriate level of money available to the employee in compliance with Labor Code section 4658.5.
(f) The mandatory voucher form is set forth in Section 10133.57.
(g) The voucher shall certify that the school is approved and if outside of California, approval is required similarly to the Bureau for Private Postsecondary (BPPVE).
(h) The claims administrator shall issue the reimbursement payments to the employee or direct payments to the VRTWC and the training providers within 45 calendar days from receipt of the completed voucher, receipts and documentation.

Note: Authority cited: Sections 133, 4658.5, 4658.6 and 5307.3, Labor Code. Reference: Sections 4658.5 and 4658.6, Labor Code.

s 10133.57. Form DWC-AD10133.57 "Supplemental Job Displacement Nontransferable Training Voucher Form." (continued)