Form OWCP-16 Rehabilitation Plan and Award

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Rehabilitation Plan And Award

U.S. Department of Labor
Employment Standards Administration
Office of Workers' Compensation Programs

INSTRUCTIONS: Complete items 1 through 13 and send to the Division of Rehabilitation. Attach the maintenance request,
OMB No. 1215-0067
Expires: 07-31-08
complete testing or work evaluation information and the justification for the rehabilitation program. No further monies or other
benefits may be paid out under this program unless this report is completed and filed as required by existing law and
regulations. OWCP exercises discretion to terminate or revise the plan when it becomes evident that the planned conditions
will not be met. Note: Persons are not required to respond to this collection of information unless It displays a
currently valid OMB control number.
2.Date of Birth(Mo.,Day,yr.)
3.OWCP No.
1 . Name of injured worker (First, middle initial, last)
4.

Address (Number, street, city, state, ZIP Code)

5. Rehabilitation services or program

6. Rehabilitation period (Month, day, year)

7. Name and address of rehabilitation facilitator (school, etc.)

8. Is this complete plan?

From

to
No - Explain

Yes
9. Occupation after rehabilitation program
11. REHABILITATION COST
a. Fees - Specify
$
$
$
$

10. Estimated yearly earnings after rehabilitation program
$
e. Other costs Specify

per
per

x
x
x

per
per
x
per
x
$
Do not include amounts previously authorized on
OWCP-35

=
=
=

$

=
=

$
$
$

per
per

x
x

per

$

per

x
x

f. TOTAL OTHER COST

b. TOTAL FEE COST

$

=

$

=
=
=
= $

g. Tuition

$

per

x

= $

h. Maintenance

$

per

x

= $

c. Supplies (Books, tools, etc.)
$

per

$

per

x
x

=

$

=

d. TOTAL SUPPLIES COST

$

TOTAL REHABILITATION COST

$

12. INJURED WORKER: I understand and approve of the provisions of this plan of services. I believe this plan will help me to get and keep
suitable employment and I will cooperate in every way possible to carry out the plan successfully.
Signature
Date signed
13. COUNSELOR RECOMMENDING PLAN: A thorough vocational evaluation was performed and employment may reasonably be expected as a
result of the implementation of the rehabilitation plan considering the interest and abilities of the injured worker, the competence of the
rehabilitation facilitator, and the nature of the job market.
Signature
FOR OWCP DISTRICT OFFICE USE ONLY BELOW THIS SPACE
14. Date of injury
15. Date of referral to OWCP
Rehabilitation

Date signed
16.

Date of referral to Rehabilitation
Agency

17. Date of maximum
medical recovery

19. Payment -This award is payable from the fund created by the
following compensation law. Mark (X) one.

18. Was there a previous plan?
No
Yes-Mark (X) one

Federal Employees' Compensation Act
Longshore and Harbor Workers' Compensation Act
District of Columbia Compensation Act

Successive to previous plan
Change of previous plan - Enter Date
20. RECOMMENDATION OF OWCP REHABILITATION SPECIALIST: The injured worker meets the eligibility requirements for OWCP rehabilitation
services. I have reviewed the rehabilitation plan and find it within the interest and ability of the injured worker. The facilitator is competent
to provide the services.
Date signed

Signature

21. APPROVAL OF DISTRICT DIRECTOR: I concur with the OWCP rehabilitation specialist, and hereby award the foregoing benefits for
payment (1) for the purpose of providing additional compensation for maintenance and/or (2) for the purpose of providing necessary
rehabilitation services in connection with a rehabilitation plan.
Date signed

Signature
FOR NATIONAL OFFICE USE ONLY

Public Burden Statement
We estimate that it will take an average of 30 minutes to complete this collection of information, including time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. If you have any comments
regarding these estimates or any other aspect of this collection of information including suggestions for reducing this burden, send them to the Office of
Workers' Compensation Programs, U.S. Department of Labor, Room S-3229, 200 Constitution Avenue, N.W. Washington, D.C. 20210.
Copy distribution: WHITE - Compensation file

PINK - Dist. R-file
GREEN - Rehab. Agency

DO NOT SEND THE COMPLETED FORM TO THIS OFFICE

CANARY - Injured Worker
GOLDENROD - Longshore Nat'l Ofc.

Form OWCP-16
Rev. May 1995