Free Form VR-39A: Application for Renewal of Certification - Nebraska

VR-39a (07/2007)

State of Nebraska Workers' Compensation Court APPLICATION FOR RENEWAL OF CERTIFICATION VOCATIONAL REHABILITATION
Certificate No.

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

I am requesting court certification as: Vocational Rehabilitation Counselor Job Placement Specialist Both PROFESSIONAL CERTIFICATION
(Check all that apply)

CRC

CVE

ABVE

If you are approved, how do you wish to be contacted? Certification Communication: Mail______ Email______ Fax______ General and Case Communication: Mail______ Email______ Fax______

EVIDENCE OF 24 APPROVED CONTACT HOURS OF CONTINUING EDUCATION COMPLETED DURING TWO-YEAR CERTIFICATION PERIOD: Is evidence of approved contact hours attached?

Yes

No

EVIDENCE OF PROVIDING DIRECT CLIENT SERVICES IN PREVIOUS 12 MONTHS: If you have not provided services in the Nebraska Workers Compensation Court in the last 12 months, please provide evidence you have provided direct client case services during this period (such as case notes or billing with client identification removed).

Supporting documentation is attached I have provided services in Nebraska in the last 12 months
Answer the questions below by checking the appropriate response. If you answer yes to any question, you must attach a written explanation and, if appropriate, a final judgment or decree.

Have you ever voluntarily relinquished a professional license or certification, or had one revoked or suspended? 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 under charges for any ethical violation?

Yes Yes Yes

No No No

STATEMENT OF UNDERSTANDING I, the undersigned, hereby apply for renewal of certification to the Nebraska Workers' Compensation Court. I understand that the Workers' Compensation Court is the sole judge of my eligibility for renewal. Additionally, I understand that renewal of certification is contingent upon my satisfying all criteria for training and/or experience established by the Workers' Compensation Court including the submission of all required documents and references. I also understand that any false, inaccurate or misleading statements included here will constitute grounds for the revocation of the certification(s) awarded on the basis of the information contained herein. Furthermore, I agree that data resulting from my participation may be used in a confidential manner for research and statistical purposes. I certify that I have read and understand the Nebraska Workers' Compensation Court's Ethical Standards and Responsibilities. I furthermore agree to abide by the provisions outlined therein as a condition of the acceptance of my application.

Signature

Date Signed

VR-39a (07/2007)

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.

Effective 11/16/2006