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California Division of Workers' Compensation
EMPLOYEE STATEMENT OF DECLINATION
OF VOCATIONAL REHABILITATION SERVICES
Purpose:
To record the employee's declination of rehabilitation services for injuries between 1/1/90 and 12/31/93, inclusive.
Submitted by:
Claims Administrator.
When submitted:
When the employee chooses to decline vocational rehabilitation services.
Where submitted:
With the RU-105 to the applicable Rehabilitation Unit district office
Form completion:
Identifying data completed by Claims Administrator
Signature of employee and attorney, if represented.
Accompanying documents:
Notice of Termination of Rehabilitation Services RU-105;
A copy of the Notice of Potential Eligibility;
Verification of the 90 day explanation of rights by a QRR;
Response to the RU-103:
The other parties shall have twenty (20) days to respond by forwarding their position, with supporting information, to the applicable Rehabilitation Unit district office with copies to all parties.
Rehabilitation Unit action:
If the employee objects to the employer's Notice of Termination, the Rehabilitation Unit shall, within 30 days, schedule a conference or otherwise obtain the employee's reason for objection together with substantiating evidence and issue its decision.
Copy:
All parties.
NOTE
Authority cited: Sections 133, 139.5 and 5307.3, Labor Code. Reference: Sections 4641 and 4644, Labor Code.
HISTORY
1. New section and new Form RU-107 and form filing instructions filed 1-29-2003;
operative 1-29-2003 pursuant to Government Code section 11343.4 (Register 2003,
No. 5).
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