Free Form VR-44JPI: Job Placement Information and Instructions - Nebraska

VR-44JPI (10/05)

Nebraska Workers' Compensation Court JOB PLACEMENT INFORMATION & INSTRUCTIONS

Please READ and keep this information so you can refer to it when necessary. Responsibilities: Several parties, including you, have distinct responsibilities in order for your job placement efforts to be successful. The following describe some of the responsibilities each of the parties, including you, have: a. Injured Worker (You). You are responsible to actively look for a job. The vocational rehabilitation counselor and the job placement specialist are not responsible for finding you a job. You are expected to follow through on the job placement activities recommended and to comply with the vocational rehabilitation counselor's expectations. It is your responsibility to keep all appointments. Tell your vocational rehabilitation counselor or job placement specialist about your progress. Be sure to keep your vocational rehabilitation counselor or job placement specialist informed about any change in your address, telephone number, or physical condition. If you get a job, contact your vocational rehabilitation counselor or job placement specialist immediately. b. Vocational Rehabilitation Counselor. The vocational rehabilitation counselor will work closely with you, any potential employer, and the Workers' Compensation Court in order to help you find suitable employment. The vocational rehabilitation counselor may give you some job leads, answer questions, help you develop (or improve) your job seeking skills, provide guidance and/or counseling if you encounter difficulties, and work closely with the Court and others in order to get you the specialized help you might need in order to secure employment. A job placement specialist chosen by the counselor may assist with these activities

c. The Insurer/Claim Representative. The claim representative is the person responsible for handling your claim and sending your weekly (temporary) disability checks while you are participating in the approved plan. If your check is late or missing, you should contact the claim representative. d. Workers' Compensation Court. The Workers' Compensation Court's Vocational Rehabilitation Specialist provides general administrative oversight of your Vocational Rehabilitation Plan, authorizes purchase of and payment for reasonable and necessary expenses associated with your approved Vocational Rehabilitation Plan. Payments: a. Court. The Workers' Compensation Trust Fund, administered by the Workers' Compensation Court, will pay those costs directly related to your job placement activities. 1. Mileage. The Court will reimburse you for travel for valid, job placement related activities. You may be reimbursed for up to 345 miles per week. To request reimbursement for your mileage, you must complete a "Job Search Activity Log ­ Mileage Reimbursement Request." Your counselor will provide the form and instructions for completing it. Submit the completed request to your vocational rehabilitation counselor for review and verification.
Nebraska Worker's Compensation Court State Capitol PO Box 98908 Lincoln, NE 68509-8908 (800)599-5155 (402)471-6468

VR-44JPI (10/05)

Once approved, the vocational rehabilitation counselor will submit the original signed form to the Court. It takes approximately three weeks from the date the Court receives the request for a reimbursement check to be sent to you. 2. Employment Related Expenses. If an employer requires you to have special clothing items or uniforms, special tools or equipment, or other specific items in order to be employed, contact your vocational rehabilitation counselor immediately. With prior approval from the Court's Rehabilitation Specialist, the Workers' Compensation Trust Fund may purchase or reimburse you for these items. The vocational rehabilitation counselor will help submit the required documents necessary for approval. 3. Other Expenses. If you have other job search related expenses, notify your vocational rehabilitation counselor immediately. The vocational rehabilitation counselor may contact the Court or the claim representative to determine whether assistance with the expense is available. b. Insurer. Your disability payments are made by the claim representative. Any questions regarding your benefits should be directed to the claim representative. You and your vocational rehabilitation counselor will set up a schedule for discussing your progress and submitting your requests for mileage reimbursement. If you get a job, you must contact your vocational rehabilitation counselor immediately. If your vocational rehabilitation counselor is unable to help you, the counselor will refer you to the Court's Vocational Rehabilitation Specialist handling your case. The Court's toll-free telephone number is (800) 599-5155 or in Lincoln you can call 471-6468. All mail should be sent to: Vocational Rehabilitation Section Workers' Compensation Court State Capitol Building P.O. Box 98908 Lincoln, NE 68509-8908

FAILURE TO FOLLOW THESE INSTRUCTIONS MAY RESULT IN DENIAL OF REIMBURSEMENT OR CANCELLATION OF YOUR PLAN. I have read and I understand the Job Placement Information and Instructions. I have been given a copy of them for my records and future reference.

Employee Signature

Date

I have reviewed this information with the employee and retained a copy of the signed form in my records.

Vocational Rehabilitation Counselor Signature
Nebraska Worker's Compensation Court State Capitol PO Box 98908

Date
Lincoln, NE 68509-8908 (800)599-5155 (402)471-6468