Free vr42.pmd - Nebraska

Nebraska Workers' Compensation Court State Capitol Building P.O. Box 98908 Lincoln, Nebraska 68509-8908 WHEN COMPLETED, MAIL TO ABOVE ADDRESS

VR-42 (10/04)

VOCATIONAL REHABILITATION COUNSELOR DESIGNATION
SOCIAL SECURITY NUMBER: E I M P S L O R Y E R E PHONE NUMBER: DATE OF BIRTH: CLAIM REPRESENTATIVE: PHONE NUMBER: CITY, STATE, ZIP CODE: E CITY, STATE, ZIP CODE: STREET ADDRESS: U STREET ADDRESS: NAME: N COMPANY NAME: DATE OF INJURY: CLAIM NUMBER:

EMPLOYER NAME:

EMPLOYER ADDRESS:

EMPLOYEE'S DIAGNOSED DISABILITY / INJURY:

EMPLOYEE'S RESTRICTIONS / LIMITATIONS:

VOC. REHAB. COUNSELOR:

WCC CERTIFICATION NUMBER:

VOC. REHAB. COUNSELOR'S AGENCY:

STREET ADDRESS:

CITY, STATE, ZIP:

TELEPHONE NUMBER:

SERVICES PLANNED: LOEP EVALUATION VOC. EVALUATION RTW COORDINATION REHAB. PLAN DEVELOPMENT OTHER (SPECIFY)

VOC. REHAB. COUNSELOR CERTIFICATION:
PURSUANT TO RULES 37 AND 42, NEBRASKA WORKERS' COMPENSATION COURT RULES OF PROCEDURE, I HEREBY NOTIFY YOU THAT I HAVE BEEN RETAINED TO PROVIDE VOCATIONAL REHABILITATION SERVICES TO THE ABOVE-NAMED INDIVIDUAL. FURTHERMORE, I CERTIFY THAT BOTH THE EMPLOYEE AND THE EMPLOYER OR HIS OR HER INSURER HAVE AGREED UPON MY SELECTION TO PROVIDE VOCATIONAL REHABILITATION SERVICES.

VOCATIONAL REHABILITATION COUNSELOR SIGNATURE:

DATE EMPLOYEE SIGNED AGREEMENT TO SELECTION:

PREPARER'S PRINTED NAME:

DATE REPORT PREPARED: