KANSAS DEPARTMENT OF LABOR www.dol.ks.gov Page 1 of 2 QUALIFIED REHABILITATION PROFESSIONAL APPLICATION (K.A.R. 51-24-5) K-WC-R 93-11 (2-14) Check disciplines you are requesting approval for: Vocational Rehabilitation Counselor Vocational Rehabilitation Evaluator Vocational Rehabilitation Job Placement Specialist Individuals proposing to qualify as a rehabilitation professional must: · Carefully review this application before completing · Provide all information requested in this application · Agree to and abide by all requirements contained within · Sign the application · ObtainaQualifiedRehabilitationProfessional(QRP)numberfromtheDivisionofWorkersCompensationpriorto accepting referrals Bysigningthisapplication,theapplicantaffirmsandagreestothefollowing: I have attached, with this application, proof that I meet the educational and/or experience required for each discipline checkedaboveasperK.A.R.51-24-5.Proofisprovidedintheformofundergraduate,graduateandPhDtranscriptsand adetailedrésuméemphasizingworkexperiencerequiredbyeachdiscipline. Ihaveprovidedmyaddressandphonenumberwiththisapplication. Ihaveprovidedthename,addressandphonenumberofthequalifiedvendorwithwhomIamaffiliated.Iwillalsonotify theDivisionofWorkersCompensationwhen,andif,Ichangeaffiliations.Ifnotpresentlyaffiliatedwithanapproved vendor,IwillnotifytheDivisionofWorkersCompensationwhenthisoccurs. IacknowledgethatmyqualificationsmaybesuspendedorrevokedifIperformworkinarehabilitationdisciplineother thanadisciplineinwhichIhavebeenfoundtobequalifiedbytherehabilitationadministrator. IacknowledgethatmyqualificationsmaybesuspendedorrevokedifIrepeatedlyfailtofilereportswiththeDirectorof WorkersCompensationinatimelymannerorfailtocomplywiththeregulationsadoptedbytheDirector. I have read and agree to abide by the standards of conduct for vocational rehabilitation vendors and vocational rehabilitationprofessionalsperK.A.R.51-24-8. I have read and understand the procedure for reviewing and processing complaints of violations of standards of conduct perK.A.R.51-24-9. IhavereadandunderstandthepenaltiesforviolationsofstandardsofconductperK.A.R.51-24-10. DIVISION OF WORKERS COMPENSATION ­ REHABILITATION UNIT 401SWTopekaBlvd.,Suite2,Topeka,KS66603-3105·Phone(785)296-4000,ext.2152·wcrehab@dol.ks.gov American LegalNet, Inc. www.FormsWorkFlow.com Kansas Department of Labor K-WC-R 93-11 (2-14) Qualified Rehabilitation Professional Application (K.A.R. 51-24-5) Page 2 of 2 I have reviewed the Standards of Conduct for Vocational Rehabilitation Professionals and agree to be accountable under K.A.R. 51-24-1 through K.A.R. 51-24-10, and all provisions of the Kansas Workers Compensation Act. Signature:_______________________________________________________________________________ Printedname:____________________________________________________________________________ Street:__________________________________________________________________________________ City:_______________________________________________________State: _______ ZIP: __________________ ( ) ( ) Phone:___________________________Fax:___________________________ Email: ___________________________________________________________ *NOTE:Protectingclaimants'identityisimportanttous.Pleasebeadvisedthat:(1)emailcommunicationisnotasecuremethodofcommunication;(2) anyemailthatissentbetweenyouandthisagencymaybecopiedandheldbyvariouscomputersitpassesthroughasitistransmitted;(3)personsnot participating in the communication between you and KDOL may intercept the communication by improperly accessing your computer or this agency's computerorevensomecomputerunconnectedtoeitherofusthatthisemailpassesthrough.IfyoudonotwanttocommunicatewithKDOLthrough email,pleasecallKDOLormailyourcommunicationtoKDOL,insteadofusingemail. For Agency Use Only Applicant approved in the following disciplines: Vocational Rehabilitation Counselor Vocational Rehabilitation Job Placement Specialist Applicant not approved in the following disciplines: Vocational Rehabilitation Counselor Vocational Rehabilitation Job Placement Specialist QualifiedRehabilitationProfessional(QRP)NumberAssignedApplicant:____________ Reviewedby:__________________________________________________________________Date:_____________________ Vocational Rehabilitation Evaluator Vocational Rehabilitation Evaluator DIVISION OF WORKERS COMPENSATION ­ REHABILITATION UNIT 401SWTopekaBlvd.,Suite2,Topeka,KS66603-3105·Phone(785)296-4000,ext.2152·wcrehab@dol.ks.gov American LegalNet, Inc. www.FormsWorkFlow.com