Free Form VR-39: Application for Certification - Nebraska

VR-39 (2/2007)

State of Nebraska Workers' Compensation Court APPLICATION FOR CERTIFICATION VOCATIONAL REHABILITATION
Date of Application

______________________________________________________________________________ Last Name First Name M.I. ______________________________________________________________________________ Office Phone Ext. Toll Free Office Phone Ext. ______________________________________________________________________________ Fax Cell Phone Home Phone ______________________________________________________________________________ Email Company Name ______________________________________________________________________________ Certificate Mailing Address ______________________________________________________________________________ City State ZIP ______________________________________________________________________________ Case Mailing Address ______________________________________________________________________________ City State ZIP

o o o o

I am requesting court certification as: Vocational Rehabilitation Counselor Job Placement Specialist Both

PROFESSIONAL CERTIFICATION
(attach a copy of each certification claimed.)

CRC

o

CVE

o

ABVE

If you are approved, how do you wish to be contacted? Certification Communication: Mail_____ Email______ Fax______ General and Case Communication: Mail _____ Email_____ Fax_____

EDUCATIONAL REQUIREMENTS
Please include a copy of your transcripts and CEU Certificates if specialized training is being claimed in lieu of advanced education. Documents may be retained and not returned to you. Year Names/locations of colleges, universities or other Major Dates Attended Qtr. Sem Degree Graduated schools attended Hrs Hrs

SUPERVISED INTERNSHIP/PRACTICUM Complete ONLY if internships are being used in lieu of or to supplement qualifying work experience. Provide on a separate attachment a description of your duties.
Name of Program where Internship was completed Site Address (City & State)

Internship/Practicum Site Telephone Number

Dates of Internship/Practicum (Month/Day/Year)

On-Site Supervisor

Total Number of Supervised Hours

Answer the questions below by checking the appropriate response. If you answer yes to any questions, you must attach a written explanation and, if appropriate, a final judgment or decree.

Have you ever had a professional license or certification revoked, suspended or relinquished voluntarily? Have you ever been placed in a probationary status by a professional counseling credentialing body? Have you ever been convicted of a felony or are you now or have you ever been charged with any ethical violation? Have you ever been certified by the Nebraska Workers' Compensation Court? If so, provide certificate number, name at the time, and reason certification terminated.

o o o o

Yes Yes Yes Yes

o o o o

No No No No

VR-39 (2/2007)

PROFESSIONAL EMPLOYMENT EXPERIENCE
List all relevant professional employment experience which will qualify you for certification. Begin with the MOST RECENT position. Attach a separate sheet if necessary.
Name of Employer: Employer Address: Dates of Employment: From Job Title: Description of Duties: To Name of Supervisor: #Hrs per Week Phone #

Reason for Leaving:

Name of Employer: Employer Address: Dates of Employment: From Job Title: Description of Duties: To Name of Supervisor: #Hrs per Week Phone #

Reason for Leaving:

Name of Employer: Employer Address: Dates of Employment: From Job Title: Description of Duties: To Name of Supervisor: #Hrs per Week Phone #

Reason for Leaving:

STATEMENT OF UNDERSTANDING
I, the undersigned, hereby apply for certification to the Nebraska Workers' Compensation Court. I understand the Nebraska Workers' Compensation Court is the sole judge of my eligibility for certification. I understand certification is contingent on my satisfying all criteria for training and/or experience established by the Nebraska Workers' Compensation Court, including the submission of all required documents. I also understand any false, inaccurate or misleading statements in this application may result in denial or revocation of certification. I agree that data resulting from my participation may be used in a confidential manner for research and statistical purposes.
Signature Date Signed

Please sign and return the Nebraska Worker's Compensation Court's Ethical Standards and Responsibilities with your application.

VR-39 (2/2007)

NEBRASKA WORKERS' COMPENSATION COURT ETHICAL STANDARDS AND RESPONSIBILITIES
(1)
A vocational rehabilitation service provider seeking certification from the court as a vocational rehabilitation counselor and/or job placement specialist shall, with the application for certification, agree to comply with the following ethical standards and responsibilities: (a) (b) The vocational rehabilitation service provider's primary obligation is to the injured employee; The vocational rehabilitation service provider shall not engage in any activity which shall endanger the health, safety, or welfare of the injured employee, and will at all times respect the integrity and privacy of the injured employee; The vocational rehabilitation service provider shall not misrepresent his or her duties or credentials; The vocational rehabilitation service provider shall be unbiased and shall demonstrate honesty and objectivity in all interactions with the injured employee and other parties, including writing of reports, charging for professional services, and administration, scoring, interpretation and utilization of assessment instruments; The vocational rehabilitation service provider shall not conduct any psychometric or other evaluation that is beyond his or her scope of practice to administer, score, interpret, or utilize; The vocational rehabilitation service provider shall not recommend any medical examination, procedure, or test that is beyond his or her scope of practice to interpret or utilize; The vocational rehabilitation service provider shall disclose his or her purpose and role in providing vocational rehabilitation services to the injured employee. This shall be done in writing at the outset of the relationship, and shall include a notice that the injured employee has the right to disagree with a proposed vocational rehabilitation plan and the consequences of such a disagreement; The vocational rehabilitation service provider shall clearly identify to the injured employee all proposed vocational rehabilitation goals designed to help the injured employee return to suitable employment. Before submitting any vocational rehabilitation plan to the court, the vocational rehabilitation service provider shall ensure the injured employee clearly understands the vocational goals being proposed, the proposed method to attain those goals, and the period in which the goals are to be attained. If the injured employee disagrees with or refuses to sign the plan, the rehabilitation service provider shall also submit to the court a brief statement as to why the injured employee disagrees with or refuses to sign the plan; The vocational rehabilitation service provider shall not, except with agreement of all parties, attempt to influence the selection of a physician or other health professional, whether for purposes of examination or treatment; The vocational rehabilitation service provider shall not attempt to influence the medical opinion of a physician or other health professional; The vocational rehabilitation service provider shall not give legal advice, in any form, to the injured employee or advise the injured employee that legal assistance is not needed; The vocational rehabilitation service provider shall not engage in sexual harassment of an injured employee. "Sexual harassment" means deliberate or repeated unsolicited comments, gestures, or physical contact of a sexual nature. The vocational rehabilitation service provider shall not solicit referrals, either directly or indirectly, by offering money and/or gifts;

(c) (d)

(e)

(f)

(g)

(h)

(i)

(j)

(k)

(l)

(m)

(2)

Failure to adhere to the above Ethical Standards and Responsibilities or failure to comply with the Code of Professional Ethics of The Commission on Rehabilitation Counselor Certification (CRCC), whether or not the vocational rehabilitation service provider is a member of such organization, may result in denial or revocation of certification or certification being placed in a probationary status.

I have read and agree to abide by these standards.
________________________________________________________________
Signature of Counselor or Specialist/Date Effective 11/16/2006