VR-42C AGREEMENT FOR THE SELECTION OF A VOCATIONAL REHABILITATION COUNSELOR Workers' Compensation Court State of Nebraska P. O. Box 98908 Lincoln, NE 68509-8908 (402) 471-6468 (Lincoln Area) (800) 599-5155 (Toll Free) Fax- (402) 742-8311 ______________________________________________________________________________ I, ___________________________, have agreed on the selection of_______________________ as the vocational rehabilitation counselor to provide vocational rehabilitation services and/or perform a loss of earning power evaluation. arising out of a work-related injury occurring on ____________________________. I understand that: I have the right to agree to the proposed vocational rehabilitation counselor to provide vocational rehabilitation services and/or perform a loss of earning power evaluation. 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______________ Day of ______________, 20_____, and I understand my rights as set forth above. Signature of Employee I verify that I have given ________________________________________ a copy of this Agreement on this_____________ day of ______________________, 20____. Signature of Counselor Date (1/13) American LegalNet, Inc. www.FormsWorkFlow.com