California Regulations 10133.19

[Form RU-107A and Instructions attached]

EMPLOYEE STATEMENT OF DECLINATION OF VOCATIONAL REHABILITATION SERVICES

Purpose:

To record the employee's declination of rehabilitation services for injuries on or after 1/1/94.

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.

Rehabilitation Unit action:

If the employee objects to the 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, relocation and amendment of Form RU-107-A from section 10133 to section 10133.19, and new form filing instructions filed 1-29-2003; operative 1-29-2003 pursuant to Government Code section 11343.4 (Register 2003, No. 5).