Free Microsoft Word - VRdisclosure - Vermont

www.labor.vermont.gov

Department of Labor Workers' Compensation PO Box 488 Montpelier, VT 05601-0488 (802) 828-2286

State File No.: Ins. Co. File No.: Date of Injury:

VOCATIONAL REHABILITATION DISCLOSURE STATEMENT

I, , am a vocational rehabilitation counselor certified by the Department of Labor, to provide vocational of for the purpose of determining your rehabilitation services. You have been referred by entitlement to vocational rehabilitation services. I am not an employee of the State of Vermont. Like other professionals involved in your recovery from your work injury, all vocational rehabilitation counselors are paid by the insurance carrier for their professional services. Vocational rehabilitation services are provided at no cost to injured workers. To determine your entitlement to vocational rehabilitation services and to provide such services, information regarding your work injury and vocational status may be obtained from, and shared with, your physician(s), other health care provider(s), employer(s), and other professionals involved in assisting you in your safe return to suitable employment. According to Vermont law, you have the right to request a change of vocational rehabilitation counselors if you are dissatisfied with my services. You may select a vocational rehabilitation counselor from a list provided by the Vermont Department of Labor, which can be found at the Department of Labor website: www.labor.state.vt.us. Your complaints, questions, or concerns regarding vocational rehabilitation services may be brought to the attention of my supervisor, , at , or they may be filed with Trudy Smith at the Vermont Department of Labor at (802) 828-2991. Participation in the vocational rehabilitation process is voluntary. Should you choose to decline services, you will need to contact the Vermont Department of Labor to re-initiate vocational rehabilitation services in the future. You are requested to sign this disclosure statement to confirm that this statement has been explained to you. Declining to sign this statement will not jeopardize any future benefits. I confirm that this statement has been thoroughly reviewed and explained to me by the counselor.

Employee Name (Please Print)

Employee Signature

Date

VR Counselor Name (Please Print)

VR Counselor Signature

Date

Rev. 02/07
The State of Vermont is an Equal Opportunity/Affirmative Action Employer. Applications from women, individuals with disabilities, and people from diverse cultural backgrounds are encouraged. Auxiliary aids and services are available upon request to individuals with disabilities. 711 (TTY/Relay Service) or 802-828-4203 TD