Fillable R2 Rehabilitation Plan (Page 4 of 4) in pdf

misrepresenting, misstating or failing to disclose any material fact is guilty of theft and shall be sentenced pursuant to Minn. Stat. § 609.52,

subd. 3.

Instructions to QRC

Completing the R-2 Rehabilitation Plan Form

Purpose: The Rehabilitation Plan form documents the services proposed to be provided to the employee by the QRC and the

responsibilities of the QRC, insurer and employee. The form also instructs the parties about how to proceed if there is a dispute regarding

the plan and gives information about data privacy and confidentiality. See Minn. Rules 5220.0410.

Instructions for items 21 to 24: Enter information about the job the employee had at the time of injury and the physical demands of the

job. See Dictionary of Occupational Titles physical demands and strength ratings description.

Service codes and descriptions: See Minn. Rules 5220.0100 for service code definitions. However, for service codes 10A and 10B the

statutory definition of job development in Minn. Stat. § 176.102, subd. 5, amends the definitions in Minn. Rules 5220.0100, subps. 16 and

18, as provided below.

Service code 10A: “Job development” means systematic contact with prospective employers resulting in opportunities for interviews

and employment that might not otherwise have existed and includes identification of job leads and arranging for job interviews. Job

development facilitates a prospective employer’s consideration of a qualified employee for employment. See Minn. Stat. § 176.102,

subd. 5(b), for the maximum number of hours and weeks of job development services for dates of injury on or after October 1, 2013.

Service code 10B: “Job placement” means activities that support a qualified employee’s search for work including the preparation of a

client to conduct an effective job search and communication of information about the labor market, programs or laws offering

employment incentives and the qualified employee’s physical limitations and capabilities as permitted by data privacy laws.

List only the services to be provided during the R-2 plan period. In the description column specify the activities to be performed within the

service category. Enter the projected cost and projected completion date for each of the services. The rehabilitation consultation service

category has been pre-filled. Enter the actual Rehabilitation Consultation Report form invoice total in the box marked “Total projected cost.”

Responsibility section: Review these instructions with the employee.

Signature block: The QRC, employee and insurer representative sign here. If a QRC intern is completing the R-2 form, the QRC intern’s

supervisor must also sign the form before it is forwarded to the parties for their review.

From the Dictionary of Occupational Titles: Definition Trailer Abridged

Strength rating (strength) -- The Physical Demands Strength Rating reflects the estimated overall strength requirement of the job,

expressed in terms of the letter corresponding to the particular strength rating. It represents the strength requirements which are

considered to be important for average, successful work performance.

S-sedentary work -- Exerting up to 10 pounds of force occasionally (occasionally: activity or condition exists up to 1/3 of the time) and/or a

negligible amount of force frequently (frequently: activity or condition exists from 1/3 to 2/3 of the time) to lift, carry, push, pull, or otherwise

move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief

periods of time. Jobs are sedentary if walking and standing are required only occasionally and all other sedentary criteria are met.

L-light work -- Exerting up to 20 pounds of force occasionally, and/or up to 10 pounds of force frequently, and/or a negligible amount of

force constantly (constantly: activity or condition exists 2/3 or more of the time) to move objects. Physical demand requirements are in

excess of those for sedentary work. Even though the weight lifted may be only a negligible amount, a job should be rated light work: (1)

when it requires walking or standing to a significant degree; or (2) when it requires sitting most of the time but entails pushing and/or pulling

of arm or leg controls; and/or (3) when the job requires working at a production rate pace entailing the constant pushing and/or pulling of

materials even though the weight of those materials is negligible. Note: The constant stress and strain of maintaining a production rate

pace, especially in an industrial setting, can be and is physically demanding of a worker even though the amount of force exerted is

negligible.

M-medium work -- Exerting 20 to 50 pounds of force occasionally, and/or 10 to 25 pounds of force frequently, and/or greater than negligible

up to 10 pounds of force constantly to move objects. Physical demand requirements are in excess of those for light work.

H-heavy work -- Exerting 50 to 100 pounds of force occasionally, and/or 25 to 50 pounds of force frequently, and/or 10 to 20 pounds of

force constantly to move objects. Physical demand requirements are in excess of those for medium work.

V-very heavy work -- Exerting in excess of 100 pounds of force occasionally, and/or in excess of 50 pounds of force frequently, and/or in

excess of 20 pounds of force constantly to move objects. Physical demand requirements are in excess of those for heavy work. (See

for additional information.)

R2 Rehabilitation Plan Page 4

Related Articles

Related forms

Related Categories