Vocational Rehabilitation (VR) Forms and Publications

Publications

• Return-to-Work Services (English and Spanish)

• Rules 36 - 45

Please contact us with questions or comments.

VR Counselor Forms

• Form VR-39: Application for Certification. NOTE: Sign and return the Ethical Standards and Responsibilities agreement with this application.

• Form VR-39A: Application for Renewal of Certification. NOTE: Sign and return the Ethical Standards and Responsibilities agreement with this application.

• Form VR-42: VR Counselor Designation

• Form VR-42B: VR Counselor Appointment Request. NOTE: Send one copy each to the Nebraska Workers’ Compensation Court, Employer / Insurer / Insurer Attorney, and Employee / Employee Attorney.

• Form VR-42C: Agreement for the Selection of a VR Counselor (English and Spanish)

• Form VR-43: Request for Change of VR Counselor. NOTE: Send one copy each to the Nebraska Workers’ Compensation Court, Employer / Insurer / Insurer Attorney, Employee / Employee Attorney, and current Vocational Rehabilitation Counselor.

VR Plan Forms

• Form VR-44: VR Plan. NOTE: All submissions of this form must include a completed US Citizenship Attestation Form (below).

• Form VR-44S: Supplemental Billing Request

• Form VR-44SI(A): Formal Training Employee Student Information and Instructions

• Form VR-44SI(B): Job Placement Information and Instructions

• Form VR-44SI(C): Supportive Services Employee Student Information and Instructions (English and Spanish)

• United States Citizenship Attestation Form (English and Spanish). NOTE: This form must accompany all submissions of form VR-44: VR Plan (above). Select this link to view resources for the Systematic Alien Verification for Entitlements (SAVE) program.

• Instructor’s Progress Report

• Labor Market Survey. NOTE: This is a voluntary form.

• Program of Study. NOTE: This is a voluntary form.

• Monthly Tutor Payment Report

VR Mileage Reimbursement Forms

• Job Search Activity Log Mileage Reimbursement Request

• Formal Training Mileage Reimbursement Request

• Supportive Services (GED, ELL, ABE, Other) Mileage Reimbursement Request

• Mileage Payment Schedule

VR Closure Forms

• Form VR-37E1: Closure Report — Case Closure — No Plan Proposed

• Form VR-37E2: Closure Report — Case Closure — Plan(s) Submitted to the Court

• Form VR-37E3: Closure Report — Plan Closure Report

• Form VR-37E4: Follow-Up Employment Status Report (English and Spanish)

Working out a disagreement

• Informally working out a disagreement

• Formally working out a disagreement