Fill and Sign the Rehab Specialist Certification Application for Workers Compensation Wisconsin Form

                                                                                                  Home Office Employer CRC CDMS CVC WI Professional Counselor License                                     ( ) ( ) ( ) ( ) ( ) ( ) ( )Wisconsin Department of Workforce Development SEND COMPLETED FORM TO: DO NOT WRITE IN THIS SPACE Worker's Compensation Division Vocational Rehabilitation Unit 201 E Washington Ave. Room C100P.O. Box 7901 PROVIDER NO Madison, WI 53707-7901 Telephone: (608) 266- 1340 Fax: (608) 267-0394 Private Vocational Rehabilitation Specialist Certification Application Important Note: All persons who provide private-sector vocational rehabilitation services under the State of Wisconsin's Worker's Compensation Act must be certified by the Worker's Compensation Division prior to providing services to injured workers. Failure to complete and submit this form for approval may result in non-payment for rehabilitation services provided to injured workers. Changes in qualification status must be reported immediately to the Worker's Compensation Division. Personal information you provide may be used for secondary purposes [Privacy Law, s. 15.04(l)(m)]. Please Print or Type I. PERSONAL DATA Applicant Name (last, first, m.i.) Telephone Number Fax Number Applicant Mailing Address (number, street, city, state and zip code) Employer Telephone Number Fax Number Employer Mailing Address (number, street, city, state and zip code) Check where WC claimants should contact you: II. QUALIFICATIONS To be certified by the Worker's Compensation Division, you must have a current CRC, CDMS, CVE, State of Wisconsin Professional Counselor license, or comparable qualifications. Attach a copy of your certification. Certification held: If you do not have any of the listed certifications, you must submit comparable qualifications with this application. Also, list 3 professional references below: (1 ) Name Positio n Telephone No. (2 ) Name Positio n Telephone No. (3 ) Name Positio n Telephone No. WKC-10042(R.08/2000) - 1 - (Over)                                                                                                                        Date Signed:       General Academic Qualifications: Earned Degree Major Area Date Awarded InstitutionIII. EXPERIENCE IN VOCATIONAL REHABILITATION EMPLOYMENT Employment Data (Current job first. List recent positions involving rehabilitation responsibilities.) PLEASE DO NOT SEND RESUME. Employer Name Location Your Occupation From To Employer Name Location Your Occupation From To Employer Name Location Your Occupation From To As a certified specialist, you will provide WC claimants with a full range of re-employment services. Please describe your training and experience in analyzing transferable skills, testing, job placement and retraining plan development. Identify up to 6 Wisconsin cities where you will provide services: Which Wisconsin counties do these cities represent: IV. APPLICANT AFFIRMATION AND SIGNATURE: I request to be certified by the State of Wisconsin Worker's Compensation Division as a private Vocational Rehabilitation Specialist. The information I provided above is correct and true to the best of my knowledge. I am now available to provide the necessary services injured workers may need to return to work. Applicant Signature: -2-