Notice Of Intention To Claim Reimbursement From The Second Injury Fund Page 2

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VOCATIONAL REHABILITATION AND WORK STATUS REPORT
1. Has the employee returned to work?
Yes
No
Do temporary partial benefits continue to be paid?
Yes
No
2. Has this case been referred for vocational rehabilitation?
Yes
(Complete #3)
No
Reason:
Disability Status Report filed requesting rehabilitation waiver
3. Current status (check ALL that apply):
a. Plan in progress, R-2 submitted
b. On-The-Job Training Plan approved and in progress
c. Retraining approved and in progress
d. Rehabilitation closed, R-8 submitted (check one below):
1. Employee returned to work
2. Employee retired
3. Employee died
4. Rehabilitation discontinued by settlement, mediation, arbitration or order
5. Other
Explain:
Mail or fax completed copy to:
In Person
Mailing Address
Fax
Department of Labor and Industry
Department of Labor and Industry
(651) 215-9099
Special Compensation Fund
Special Compensation Fund
443 Lafayette Road N.
PO Box 64229
St. Paul, MN 55155-4301
St. Paul, MN 55164-0229

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