Form Dwc-20 - Individualized Written Reemployment Plan
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2FLORIDA DEPARTMENT OF LABOR & EMPLOYMENT SECURITY
DIVISION OF WORKERS' COMPENSATION
BUREAU OF REHABILITATION & MEDICAL SERVICES
2728 Centerview Drive, 100 Forrest Building
Tallahassee, Florida 32399-0664
INDIVIDUALIZED WRITTEN REEMPLOYMENT PLAN
1. EMPLOYEE NAME
2. SOCIAL SECURITY NUMBER
3. DATE OF ACCIDENT
4. EMPLOYEE ADDRESS
5. OCCUPATION
6. CARRIER NAME
(at time of injury)
7. PROVIDER/COMPANY NAME
8. PROVIDER/COMPANY ID
NUMBER
9. REEMPLOYMENT GOALS/OBJECTIVES
10. TYPE OF PLAN
A.
Return to work, same employer, same job.
Reemployment Assessment
B.
Return to work, same employer, modified or different job.
Reemployment Plan
C.
Return to work, different employer, same job.
Division Reemployment Services
D.
Return to work, different employer, modified or different job.
11. Description of proposed services:
13. DATE
14. DATE
15. TOTAL
12. SERVICE
TO BE
TO BE
ESTIMATED
INITIATED
COMPLETED
COST
Generic Services (020-099)
Intake Services (101-199)
Physical Rehabilitation Coordination (201-299)
Vocational Assistance/Assessment (301-399)
Placement Services (401-499)
Interdisciplinary Rehabilitation Programs (501-599)
Support Services (601-699)
Training (701-799)
Psychometric Tests and Work Samples (801-999)
LES Form DWC-20 (08/30/95)
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