Form Dwc-24 - Agency And Student Agreement For Sponsorship Of Retraining printable pdf download

FLORIDA DEPARTMENT OF LABOR AND EMPLOYMENT SECURITY

DIVISION OF WORKERS' COMPENSATION

BUREAU OF REHABILITATION AND MEDICAL SERVICES

2728 Centerview Drive, 100 Forrest Building

Tallahassee, Florida 32399-0664

AGENCY AND STUDENT AGREEMENT FOR SPONSORSHIP OF RETRAINING

NAME

SOCIAL SECURITY NUMBER

DATE OF ACCIDENT

TRAINING PROGRAM

TRAINING FACILITY

DATES OF TRAINING

For continuation of sponsorship by the Division of an approved retraining program, the injured employee (student) has

the following responsibilities:

The student shall:

Be held liable for costs incurred for any services initiated or obtained without prior written authorization to incur

such expenses from the Division.

Upon receipt of written authorization, be responsible for completing all procedures, including remedial course

work, required for admission into the approved program at the next scheduled registration period.

Provide documentation of eligibility for in-state tuition rates prior to enrolling in a Division sponsored program.

Be responsible for transportation arrangements and costs associated with any Division sponsored retraining

program unless such travel expenses are authorized and approved by the Division in advance of the travel

pursuant to rule chapter 38F-55.015, Florida Administrative Code.

Attend the approved program as structured in the course curriculum on a full-time, continuous (year-round) basis

until completion of the program unless,

a. written approval to deviate from the approved program is received from the Division, and

b. an exacerbation of a medical condition precludes full-time attendance or participation in the approved

program and the student notifies the Division staff within 2 business days of knowledge and provides

medical documentation from the treating physician within 14 days of initial treatment. In such an

event, continuation or readmission into the approved program shall be contingent upon the

established policy of the training or education program.

Inform the Division of problems affecting attendance and grades, and of any changes in financial circumstances,

address or telephone number.

Provide proof of attendance as instructed by Division staff.

Shall meet and maintain a 2.0 grade point average or the performance criteria established by the approved

program, whichever is higher.

a. Students who do not maintain these standards have one evaluation period to achieve the required

performance standard.

b. Any courses failed, withdrawn or repeated shall be made up at the student's expense unless the

Division authorizes the re-taking of courses.

Provide documentation to the employer/carrier and Division of continuing progress in the program within 14 days

of completion of the evaluation period. For the Division, this shall be in the form of original report cards.

10.

Notify the Division of the specific courses and credits to be taken within two weeks of the next term's scheduled

registration date. College students must enroll for a minimum of 12 credit hours per term, including summer

sessions unless otherwise authorized in writing by the Division.

LES Form DWC-24 (08/30/95)

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Form Dwc-24 - Agency And Student Agreement For Sponsorship Of Retraining

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