Nebraska Workers' Compensation Court DRAFT VR - 42b Vocational Rehabilitation Section P.O. Box 98908 Lincoln, Nebraska 68509 - 8908 (402) 471 - 3606 (800) 599 - 5155 MAIL COMPLETED FORM TO ABOVE ADDRESS OR FAX TO NE WCC VR SECTION AT (402) 742 - 8311 Or email to wcc.vocrehab@nebraska.gov ( 8/ 18 ) EMPLOYEE NAME DOCKET & PAGE NO. (IF APPLICABLE) STREET ADDRESS TELEPHONE NUMBER CITY, STATE, ZIP CODE EMPLOYEE EMAIL ADDRESS EMPLOYER (NAME & ADDRESS) DATE OF INJURY INSURER (NAME & ADDRESS) CLAIM ADJUSTER EMAIL ADDRESS CLAIM NUMBER (IF KNOWN) CLAIM ADJUSTER CLAIM ADJUSTER TELEPHONE NUMBER TYPE OF INJURY HAS EMPLOYEE RETURNED TO WORK? YES NO EMPLOYEE'S ATTORNEY (NAME & ADDRESS) TELEPHONE NUMBER EMPLOYER'S / INSURER'S ATTORNEY (NAME & ADDRESS) TELEPHONE NUMBER IS THE EMPLOYEE CLAIMING ENTITLEMENT TO VOCATIONAL REHABILITATION PURSUANT TO 247 48 - 162.01? YES NO IS THE EMPLOYEE REQUESTING THAT VOCATIONAL REHABILITATION SERVICES BE PROVIDED? YES NO IS THE REQUESTOR ASKING THAT A LOSS - OF - EARNING - POWER EVAL UATION BE PERFORMED UNDER STAT U T E 48 - 121(2) ? YES NO IS THE REQUESTOR ASKING THAT A LOSS - OF - EARNING - POWER EVALUATION BE PER FORMED FOR MULTIPLE SCHEDULED MEMBERS UNDER STATUT E 48 - 121 ( 3 ) ? YES NO I S AN INTERPRETE R REQUIRED? YES NO PRIOR TO THIS REQUEST, HAS ANY PARTY RETAINED THE SERVICES OF A VOC. REHAB. COUNSELOR FOR THIS CASE? YES NO A. The requestor attests that the employee has reached max imum medical improvement. YES NO B. The requestor attests that the employee has permanent restrictions that are authored or endorsed by a physician. YES NO C. The requestor attests that the employee has temporary restrictions that are authored or endorsed by a physician. YES NO D. Employee and Employer/Insurer have attempted to agree on the selection of a vocational rehabilitation counselor for this case. YES NO E . Describe in detail: O n what basis is the request for vocational rehabilitation c ou nselor appointment being made ? NOTE: The requestor must p rovide the original or a copy of the VR - 42b to the V ocational R ehabilitation Requestor must also provide a copy of this request to all parties. [Rule 42 (A)(3)] PRINTED NAME OF REQUESTOR SIGNATURE OF REQUESTOR DATE SIGNED VOCATIONAL REHABILITATION COUNSELOR APPOINTMENT REQUEST American LegalNet, Inc. www.FormsWorkFlow.com