Form DFS-F3-DWC-24 "Department and Student Agreement for Sponsorship of Training and Education" - Florida

Form DFS-F3-DWC-24 or the "Department And Student Agreement For Sponsorship Of Training And Education" is a form issued by the Florida Department of Financial Services.

The form was last revised in December 1, 2015 and is available for digital filing. Download an up-to-date Form DFS-F3-DWC-24 in PDF-format down below or look it up on the Florida Department of Financial Services Forms website.

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Download Form DFS-F3-DWC-24 "Department and Student Agreement for Sponsorship of Training and Education" - Florida

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D
F
S
EPARTMENT OF
INANCIAL
ERVICES
Division of Workers’ Compensation - Bureau of Employee Assistance
200 East Gaines Street, Tallahassee, Florida 32399-4225
DEPARTMENT AND STUDENT AGREEMENT
FOR SPONSORSHIP OF TRAINING AND EDUCATION
Name:
Case ID:
Date of Accident:
Training Program:
Training Facility:
Dates of Training:
For continuation of sponsorship by the Department of an approved training or education program, the injured employee
(student) and the Department have responsibilities. Rule 69L-22.009, Florida Administrative Code.
The student shall:
1. Be held liable for costs incurred for any services initiated or obtained without pre-approval from the Department.
2. Upon receipt of written authorization, be responsible for completing all procedures, including remedial course work,
required for admission into the approved program at the next scheduled registration period, unless written approval is
received from the Department for postponement.
3. Provide documentation of eligibility for in-state tuition rates prior to enrolling in a Department sponsored program.
4. Be responsible for transportation arrangements, costs, and mileage up to 50 miles one way, associated with any
approved Department-sponsored program. Mileage over 50 miles one way can be reimbursed if approved by the
Department in advance of the travel.
5. Attend the approved program as structured in the course curriculum on a full-time continuous (year-round) basis until
completion of the program:
a. unless a medical condition, family emergency or financial hardship prevents full-time attendance or participation in
the approved program. The student must contact the Department staff immediately and provide documentation
within 14 calendar days of the event.
b. In such an event, continuation or readmission into the approved program shall be contingent upon the established
policy of the training or education program.
6. Inform the Department of problems affecting attendance and grades, and of any changes in financial circumstances,
address or telephone number within 14 calendar days of such an event.
7. Provide proof of attendance to the Department on a monthly basis no later than 14 calendar days after the end of
each month.
8. Meet and maintain a minimum 2.0 grade point average or the performance criteria established by the approved
program, whichever is higher.
a. Students who do not maintain these standards have one evaluation period to achieve the required performance
standard.
b. Any courses failed, withdrawn or repeated shall be made up at the student's expense. The Department may
authorize the payment of these courses, if need to repeat is due to a medical exacerbation of the workers’
compensation injury and documented by the authorized treating physician.
9. Provide copies of report cards to the employer/carrier and Department of continuing progress in the approved
program within 14 calendar days of completion of each grading period.
10. Provide copies of certificates of completion, diplomas, licenses, etc., which document completion of the approved
program, to the employer/carrier and Department within 14 calendar days of receipt.
11. Notify the Department within 14 calendar days of completion or termination of the approved program.
12. Attend the approved program on a full time basis as defined by the educational program.
13. Enroll only in courses identified in the approved program curriculum.
14. Send copies of the registration form and final class schedule to the Department at the beginning of each term.
Form DFS-F3-DWC-24, Rev. 12/2015
Page 1 of 2
Rule 69L-22.0011, F.A.C.
D
F
S
EPARTMENT OF
INANCIAL
ERVICES
Division of Workers’ Compensation - Bureau of Employee Assistance
200 East Gaines Street, Tallahassee, Florida 32399-4225
DEPARTMENT AND STUDENT AGREEMENT
FOR SPONSORSHIP OF TRAINING AND EDUCATION
Name:
Case ID:
Date of Accident:
Training Program:
Training Facility:
Dates of Training:
For continuation of sponsorship by the Department of an approved training or education program, the injured employee
(student) and the Department have responsibilities. Rule 69L-22.009, Florida Administrative Code.
The student shall:
1. Be held liable for costs incurred for any services initiated or obtained without pre-approval from the Department.
2. Upon receipt of written authorization, be responsible for completing all procedures, including remedial course work,
required for admission into the approved program at the next scheduled registration period, unless written approval is
received from the Department for postponement.
3. Provide documentation of eligibility for in-state tuition rates prior to enrolling in a Department sponsored program.
4. Be responsible for transportation arrangements, costs, and mileage up to 50 miles one way, associated with any
approved Department-sponsored program. Mileage over 50 miles one way can be reimbursed if approved by the
Department in advance of the travel.
5. Attend the approved program as structured in the course curriculum on a full-time continuous (year-round) basis until
completion of the program:
a. unless a medical condition, family emergency or financial hardship prevents full-time attendance or participation in
the approved program. The student must contact the Department staff immediately and provide documentation
within 14 calendar days of the event.
b. In such an event, continuation or readmission into the approved program shall be contingent upon the established
policy of the training or education program.
6. Inform the Department of problems affecting attendance and grades, and of any changes in financial circumstances,
address or telephone number within 14 calendar days of such an event.
7. Provide proof of attendance to the Department on a monthly basis no later than 14 calendar days after the end of
each month.
8. Meet and maintain a minimum 2.0 grade point average or the performance criteria established by the approved
program, whichever is higher.
a. Students who do not maintain these standards have one evaluation period to achieve the required performance
standard.
b. Any courses failed, withdrawn or repeated shall be made up at the student's expense. The Department may
authorize the payment of these courses, if need to repeat is due to a medical exacerbation of the workers’
compensation injury and documented by the authorized treating physician.
9. Provide copies of report cards to the employer/carrier and Department of continuing progress in the approved
program within 14 calendar days of completion of each grading period.
10. Provide copies of certificates of completion, diplomas, licenses, etc., which document completion of the approved
program, to the employer/carrier and Department within 14 calendar days of receipt.
11. Notify the Department within 14 calendar days of completion or termination of the approved program.
12. Attend the approved program on a full time basis as defined by the educational program.
13. Enroll only in courses identified in the approved program curriculum.
14. Send copies of the registration form and final class schedule to the Department at the beginning of each term.
Form DFS-F3-DWC-24, Rev. 12/2015
Page 1 of 2
Rule 69L-22.0011, F.A.C.
Name:
Case ID:
Date of Accident:
15. Be personally responsible for the purchase of books and supplies, which are not specific to the approved program and
not authorized by the Department. Such items include, but are not limited to: paper, pens, binders, notebooks, etc.
(See list attached to the Letter of Intent)
16. At the request of the Department, return any books and special supplies purchased by the Department upon
withdrawal or when the student fails to abide by this Department and Student Agreement for Sponsorship of Training
and Education.
17. Notify the Department within 14 calendar days when employment is obtained during, after completion, or upon
termination of the approved program.
The Department:
1. Has the exclusive right to determine the training and education programs and facilities at which to sponsor the injured
employee.
2. Shall only pay tuition, fees, books and special supplies directly related to the approved program and pre-authorized
by the Department.
3. Shall determine a student's eligibility for continuation or readmission into the approved program after receiving
documentation of absences due to a medical condition, family emergency, or financial hardship.
4. Shall only authorize payment of the re-taking of courses when the student was receiving a passing grade at the time
of withdrawal and had to withdraw due to a medical exacerbation of the workers’ compensation injury.
5. Shall notify the approved facility and the student in writing when a student is not authorized to enroll due to failure to
abide by this Department and Student Agreement for Sponsorship of Training and Education.
6. Shall permanently withdraw sponsorship of the approved program when the student fails to abide by the Department
and Student Agreement for Sponsorship of Training and Education and the student’s participation is interrupted for a
period greater than 180 days for reasons other than medical exacerbation of the workers’ compensation injury.
7. Reserves the right to reclaim any books and special supplies purchased by the Department upon the student’s
withdrawal from the approved training or education program or when the student fails to abide by the Department and
Student Agreement for Sponsorship of Training and Education.
8. Shall refer any student for possible fraud investigation when it appears the student has misrepresented the student’s
training status in order to receive benefits.
As a representative of the State of Florida, Department of Financial Services, Division of Workers’ Compensation, I have
discussed the above with the injured employee, and I am providing the injured employee with a copy of this document to
ensure understanding of the responsibilities and conditions of sponsorship.
Division of Workers’ Compensation Staff
Date
I understand and agree to abide by the above while participating in this Department-sponsored training or education
program.
Injured Employee
Date
Form DFS-F3-DWC-24, Rev. 12/2015
Page 2 of 2
Rule 69L-22.0011, F.A.C.
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