VR-37E4 Nebraska Workers' Compensation Court P.O. Box 98908 Lincoln, Nebraska 68509-8908 (402) 471-3606 (800) 599-5155 When Completed, Mail To Above Address or Fax to NEWCC VR Section at (402) 742-8311 or Email to WCC.VocRehabSM@nebraska.gov SUBMIT FOLLOW-UP EMPLOYMENT STATUS REPORT (See attached instructions) 30 Days 1 3 Month 6 Month 2 9 Month 1 Year Name of employee: 3 Date of injury: 4 Name of VR counselor: 5 Date of VR case closure: Employee current contact information: Name:________________________________________________________________________ Address:______________________________________________________________________ ______________________________________________________________________________ Primary telephone:______________________________________________________________ Secondary telephone:____________________________________________________________ Email:_________________________________________________________________________ 6 7 Employment status: Employed Unemployed 8 9 Employment start date: N/A Employment consistent with plan goal: Yes 10 Job title: N/A 11 No N/A Hourly wage: N/A 12 Number of hours worked per week: N/A CERTIFIED COUNSELOR SIGNATURE: Date: 6/2016 American LegalNet, Inc. www.FormsWorkFlow.com Follow-Up Employment Status Report Instructions and Descriptions This form is to be filed in any case closed on or after January 1, 2016 in which (1) the employee was unemployed at the time of case closure or the employment status was unknown, and (2) the case included an approved vocational rehabilitation plan or plans, regardless of whether a plan was successfully completed. This form shall be filed within 5 working days following 30 days, 3 months, 6 months, 9 months, and one year after case closure, so long as the employee remains unemployed. Follow-up and reporting shall cease once the employee becomes employed, whether full time or part time, and such employment is reported to the court. 1) Name of employee: Full name of employee. 2) Date of injury: Date of injury as identified on the VR plan form. 3) Name of Certified VR Counselor: Full name of counselor of record, agreed upon /appointed to VR case. 4) Date of VR case closure: Indicate date of VR case closure as indicated on the Case Closure Report-Plan or Plans Proposed form. 5) Employee contact information: If contact information has changed since the last report, indicate current contact information. 6) Employment status: Indicate with a check mark in the appropriate box if employee is currently employed or unemployed. If employment status cannot be determined leave both boxes blank and attach a written explanation of the steps taken by the counselor to contact the employee and/or otherwise determine employment status. 7) Employment start date: Indicate employee's employment start date. Place a check mark in the N/A box if the employee is not employed at the time the report is filed. 8) Employment consistent with plan goal: Indicate if the employee's employment is consistent with the job family identified in the plan closure report form. Place a check mark in the N/A box if the employee is not employed at the time the report is filed. 9) Job title: If employed, indicate the employee's job title or a term that describes the position held. Place a check mark in the N/A box if the employee is not employed at the time the report is filed. 10) Hourly wage: If applicable, indicate employee's hourly wage. Place a check mark in the N/A box if the employee is not employed at the time the report is filed. 11) Number of hours worked per week: Report the employee's hours worked per week. Place a check mark in the N/A box if the employee is not employed at the time the report is filed. 12) Certified Counselor signature and Date: The counselor of record must sign and include date of report completion. For electronic submission of the form the signature shall be typed using the signature format "/s/ [typed name]." 6/24/2016 American LegalNet, Inc. www.FormsWorkFlow.com