R2 Rehabilitation Plan
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Mail or fax to:
R-2
Department of Labor and Industry
Workers’ Compensation Division
Rehabilitation Plan
PO Box 64221
RE0 1
St. Paul, MN 55164-0221
Print in ink or type
(651) 284-5032 or 1-800-342-5354
DO NOT USE THIS SPACE
Enter dates in MM/DD/YYYY format
Fax: (651) 284-5731
1. WID number or SSN
2. Date of injury
Please fill out this form. You cannot save data typed into
this form. Please print the completed form if you would like
a copy for your records.
3. Employee name
4. Employee address
City
State
ZIP code
5. Employee phone number
6. Date of birth
7. Employer name
8. Employer contact
9. Employer phone number
10. Insurer claim number
15. QRC name
11. Insurer/self-insurer/TPA
16. QRC firm
12. Insurer address
17. QRC address
City
State
ZIP code
City
State
ZIP code
13. Claim representative
14. Phone number
18. QRC #
19. QRC firm #
20. QRC phone number
21. Occupation at time of injury
22. Pre-injury AWW
27. Highest grade completed (select one)
a. No high school diploma or GED
23. Occupational demands
b. High school diploma or GED
Sedentary
Light
Medium
Heavy
Very heavy
c. Some post-secondary course work
d. Post-secondary vocational/technical program
24. Job at date of injury
Part time
Full time
e. Bachelor’s degree
25. Employee’s current work status
f. Master’s, Ph.D. or professional degree
a. Off work from DOI to start of rehabilitation
b. Some work between DOI and start of rehabilitation, not
working at start of rehabilitation
28. Employee may require an interpreter
Yes
No
c. Working at start of rehabilitation
26. Vocational goal
29. Date of first consultation in person or telephone meeting
(#25 on RCR)
a. RTW same employer
b. RTW different employer
QRC comments
Complete all service areas to be provided during this plan
Projected
Projected
Service category
Description
completion
cost
date
Report actual consultation costs in the “projected cost” box
00 - Rehabilitation
Consultation
N/A
01 - Medical
Management
MN RE01 (8/15)
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