Free 97VR42C.P65 - Nebraska

AGREEMENT FOR THE SELECTION OF A VOCATIONAL REHABILITATION COUNSELOR
Workers Compensation Court State of Nebraska P. O. Box 98908 Lincoln, NE 685098908 (402) 471-6468 (Lincoln area & Out-of-State) (800) 599-5155 (Nebraska Only)

I, , have agreed on the selection of as the vocational rehabilitation counselor to provide vocational rehabilitation services arising out of a work-related injury occurring on .

I understand that: n n n n I have the right to agree to the proposed vocational rehabilitation counselor to provide vocational rehabilitation services. I have the right not to agree to the proposed vocational rehabilitation counselor. I have the right to propose a vocational rehabilitation counselor of my own choosing. If I cannot agree with the other party on a vocational rehabilitation counselor, I have the right to request that the Workers Compensation Court appoint a vocational rehabilitation counselor at no cost to me.

I have read this agreement on this understand my rights as set forth above.

day of

, 20

, and I

Signature of Employee I verify that I have given day of a copy of this Agreement on this .

, 20

Signature of Counselor

VR42C

Rev. 11/99