Workers' compensation forms

The forms on this page are PDFs that can be viewed or printed. The forms have been converted to fill-in PDFs that allow users to type directly into the form and then print it. The free Adobe Acrobat Reader software does not allow users the option of saving data that is typed into the fill-in PDF; for the option to save, visit www.adobe.com for more information about Adobe Acrobat software.

Experience faster data entry for dates, phone numbers and Social Security number by entering numbers only. The fill-in PDF will automatically enter the slashes for dates, the parentheses and hyphen for phone numbers and the hyphens for Social Security numbers.

Spanish version of workers' compensation forms

These forms are to be used for communication purposes only; they should not be filed with the department.

Form name Last update Notes

Derechos de Rehabilitacion y Responsabilidades del Trabajador Lesionado (IW05) May 2008 PO; WID

Informe de Consulta de Rehabilitacion (RC01) May 2008 PO; WID; Wording changes #20-24*

Informe de Progreso del Plan (PR01) May 2008 PO; WID

R-2 Plan de Rehabilitacion (RE01) May 2008 PO; TENN; WID

R-3 Enmienda al Plan de Rehabilitacion (RP01) September 2008 PO; TENN; WID

R-8 Aviso de Conclusion del Plan de Rehabilitacion (NR01) May 2008 PO; WID

Respuesta de Rehabilitacion (RR03) May 2008 PO; TENN; WID

Solicitud de Rehabilitacion (RQ03)-- [more info] May 2008 PO; TENN; WID

*Notes: DLI = department information updated; PH = phone number change; PO = new mailing address; TENN = Tennessen warning; WID = worker identification (number)**

**Worker identification number -- The department is making an effort to minimize the possibility of data privacy abuse. As part of this effort, DLI will be assigning a worker identification (WID) number to be used on forms and correspondence instead of using the injured worker's Social Security number (SSN). If the injured workers' WID number is not known, the SSN can still be entered in the space on the form, because either number can be used.

More information

Rehabilitation plan service codes and categories
Vocational rehabilitation invoice form
For more information about workers' compensation forms, contact Jana Williams, Data Management and Training director, at (651) 284-5304 or dli.wcrequest@state.mn.us.

Form name	Last update	Notes
Derechos de Rehabilitacion y Responsabilidades del Trabajador Lesionado (IW05)	May 2008	PO; WID
Informe de Consulta de Rehabilitacion (RC01)	May 2008	PO; WID; Wording changes #20-24*
Informe de Progreso del Plan (PR01)	May 2008	PO; WID
R-2 Plan de Rehabilitacion (RE01)	May 2008	PO; TENN; WID
R-3 Enmienda al Plan de Rehabilitacion (RP01)	September 2008	PO; TENN; WID
R-8 Aviso de Conclusion del Plan de Rehabilitacion (NR01)	May 2008	PO; WID
Respuesta de Rehabilitacion (RR03)	May 2008	PO; TENN; WID
Solicitud de Rehabilitacion (RQ03)-- [more info]	May 2008	PO; TENN; WID
Notes: DLI = department information updated; PH = phone number change; PO = new mailing address; TENN = Tennessen warning; WID = worker identification (number)* **Worker identification number -- The department is making an effort to minimize the possibility of data privacy abuse. As part of this effort, DLI will be assigning a worker identification (WID) number to be used on forms and correspondence instead of using the injured worker's Social Security number (SSN). If the injured workers' WID number is not known, the SSN can still be entered in the space on the form, because either number can be used.