Request For Approval Of Training Program By Vocational Rehabilitation Counselor
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Request For Approval Of Training Program By Vocational Rehabilitation Counselor Form. This is a Oregon form and can be use in Vocational Rehabilitation Workers Comp.
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Tags: Request For Approval Of Training Program By Vocational Rehabilitation Counselor, 4619, Oregon Workers Comp, Vocational Rehabilitation
Request for approval of training program
by vocational rehabilitation counselor
Name:
Fax:
Address:
Phone:
City:
State:
ZIP:
Program title:
Program date:
Program sponsor:
Continuing-education credits (CEUs) requested:
Please attach agenda and documentation of program content and explain relevance to vocational
rehabilitation practices:
Signature of requester
State of Oregon certif ication no.
Date
The Workers’ Compensation Division will approve or deny your request and return the form to you.
Please include a self-addressed, stamped envelope with your request.
If your request is approved:
Keep this approval and resubmit it at the time of renewal, along with proof of attendance and actual
continuing education units earned.
Department use only
Program approved
for
CEUs
Elaine Gumc, Lead Vocational Reviewer
Employment Services Team
Benefit Services Section
Workers’ Compensation Division
350 Winter St. NE
P.O. Box 14480
Salem, OR 97309-0405
Phone: 503-947-7768; Fax: 503-947-7794
Program not approved
Date
440-4619 (1/10/DCBS/WCD/WEB)
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