Free Wisconsin Department of - Wisconsin

Private Vocational Rehabilitation Specialist Certification Application
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DO NOT WRITE IN THIS SPACE
PROVIDER NO:____________________

Department of Workforce Development Worker's Compensation Division 201 E. Washington Ave., Rm. C100 P.O. Box 7901 Madison, WI 53707-7901 Telephone: (608) 266-1340 Fax: (608) 267-0394 http://www.dwd.state.wi.us/wc/ e-mail: [email protected]

______________________________________________________________________________________________________ Important Note: All persons who provide private-sector vocational rehabilitation services under the State of Wisconsin's Worker's Compensation Act must be certified by the Worker's Compensation Division prior to providing services to injured workers. Failure to complete and submit this form for approval may result in non-payment for rehabilitation services provided to injured workers. Changes in qualification status must be reported immediately to the Worker's Compensation Division. Please Print or Type
Personal information you provide may be used for secondary purposes [Privacy Law, s. 15.04(1)(m)].

I. PERSONAL DATA
Applicant Name (Last, First, MI) Telephone Number E-Mail Address ( )

( ) Applicant Business Mailing Address (number, street, city, state and zip code)

Employer

Telephone Number )

Fax Number ( )

( Employer Mailing Address (number, street, city, state and zip code):

II. QUALIFICATIONS
To be certified by the Worker's Compensation Division, you must have a current CRC, CDMS, CVE, State of Wisconsin Professional Counselor license, or comparable qualifications. Attach a copy of your certification. Certification held: CRC CDMS CVE WI Professional Counselor License

If you do not have any of the listed certifications, you must submit comparable qualifications with this application. Also, list 3 professional references below:

(1) _________________________ _______________________________________ Name Position

(______)___________________ Telephone No.

(2) _________________________ _______________________________________ Name Position

(______)___________________ Telephone No.

(3) _________________________ _______________________________________ Name Position

(______)___________________ Telephone No. (Over)

WKC-10042 (R. 10/2006)

General Academic Qualifications: Earned Degree: Major Area: Date Awarded: Institution:

____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________

III. EXPERIENCE IN VOCATIONAL REHABILITATION EMPLOYMENT Employment Data (Current job first. List recent positions involving rehabilitation responsibilities.) PLEASE DO NOT SEND RESUME. Employer Name: Location:

_________________________________________________________________________________________________ Your Occupation: From: To:

Employer Name:

Location:

_________________________________________________________________________________________________ Your Occupation: From: To:

Employer Name:

Location:

_________________________________________________________________________________________________ Your Occupation: From: To:

As a certified specialist, you will provide WC claimants with a full range of re-employment services. Please describe your training and experience in analyzing transferable skills, testing, job placement and retraining plan development. __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ Identify up to 6 Wisconsin cities where you will provide services: ______________________________________________

__________________________________________________________________________________________________ Which Wisconsin counties do these cities represent: ________________________________________________________ __________________________________________________________________________________________________

IV. APPLICANT AFFIRMATION AND SIGNATURE: I request certification by the State of Wisconsin Worker's Compensation Division as a private Vocational Rehabilitation Specialist. The information I have provided above is correct and true to the best of my knowledge. I am now available to provide the necessary services injured workers may need to return to work.

Applicant Signature:

_________________________________________

Date Signed:_____________________