Plan Progress Report
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Mail or fax to:
Department of Labor and Industry
Plan Progress Report
Workers’ Compensation Division
PO Box 64221
P R 0 1
St. Paul, MN 55164-0221
(651) 284-5032 or 1-800-342-5354
Print in ink or type
DO NOT USE THIS SPACE
Fax: (651) 284-5731
Enter dates in MM/DD/YYYY format
1. Date of this report
2. WID number or SSN
3. Date of injury
4. Employee name
5. Employee address
City
State
ZIP code
6. Date of rehabilitation consultation:
(#29 on R-2)
7. Employer name
8. Employer contact person
9. Phone number
10. Insurer claim number
15. QRC name
11. Insurer/self-insurer/TPA
16. QRC firm
12. Insurer address
17.Address
City
State
ZIP code
City
State
ZIP code
13. Claim representative
14. Phone number
18. QRC #
19. QRC firm #
20. Phone number
Medical report date
with
without
21. Is the employee released to return to work?
Yes,
Yes,
No
restrictions
restrictions
If working, is this a temporary job?
22. Current work
Not working
Part time
Full time
Seasonal layoff
status:
Yes
No
23. Is the plan still current?
Yes
No
Plan costs to date
Other costs necessary to complete plan
Estimated total cost
$ 0.00
24. Costs
+
=
Duration to date
Expected additional duration to plan completion
Estimated total duration
25. Plan
duration
from
plan filing date (in weeks)
+
=
0
26. Do barriers to successful completion of the rehabilitation plan exist?
Yes
No
If yes, list these on a separate sheet along with the measures to be taken to overcome those barriers, and attach it to this form.
QRC Signature
Date
QRC Intern Supervisor Signature
Date
This form is required to be filed 6 months after filing the R-2 (unless an R-3 is filed 15 days before or after 6 months have
passed since the R-2 filing date). See Minnesota Rules 5220.0450, subp. 3 A. Send copies to the employee, insurer and
attorney(s). Send to the date-of-injury employer if the goal of the rehabilitation plan is to return to work with that employer.
This form and access to the electronic submission format is located at The form can be made
available in different formats, such as large print, Braille or audio. To request, call (651) 284-5032 or 1-800-342-5354.
Any person who, with intent to defraud, receives workers’ compensation benefits to which the person is not entitled by knowingly
misrepresenting, misstating or failing to disclose any material fact is guilty of theft and shall be sentenced pursuant to Minnesota
Statutes § 609.52, subd. 3.
MN PR01 (01/2014)
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