Form 862 - Application For Vocational Rehabilitation Evaluator

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FORM 862

Application for Vocational Rehabilitation Evaluator

Please complete the following, sign under penalty of perjury and return with current resume to the:

Court of Existing Claims

ATTENTION: MEDICAL

1915 North Stiles

Oklahoma City, OK 73105-4918

ALL INFORMATION SUBMITTED TO THE COURT MAY BE CONSIDERED A PUBLIC RECORD UNDER STATE LAW. Direct all questions concerning

disclosures to 405-522-8629.

APPLICANT’S NAME:

OFFICE PHONE:

THIS SPACE FOR COURT USE ONLY

NAME OF BUSINESS:

OFFICE HOURS:

OFFICE ADDRESS:

IN WHICH CITY ARE EVALUATIONS

PERFORMED:

NAME OF CONTACT PERSON TO SCHEDULE APPOINTMENTS:

FEE FOR VOCATIONAL EVALUATION:

E-MAIL ADDRESS OF APPLICANT:

Have you evaluated workers’ compensation claimants for the Court during the past 12 months? YES

If NO, briefly describe your formal education/training in vocational rehabilitation and provide the Court with a sample vocational

evaluation report. ______________________________________________________________________________________________________

_____________________________________________________________________________________________________________________

Are you willing to accept Court-imposed limitations on the amount of money you can expect to be paid for depositions, progress reports, evaluation

reports? YES

Will you agree to serve on the Court’s list for an entire one-year period?

YES

Are you a Certified Rehabilitation Counselor? YES

Degree(s): ___________________________________________________________________________________________________________

List your national and local certifications: ___________________________________________________________________________________

_____________________________________________________________________________________________________________________

Areas of expertise: (Please check all which are applicable)

Vocational Evaluations

Job Placement: Please list Hourly Fee charged for this service: _______________________

Transferable Skills

Other (specify) ______________________________________________________________

Do you have errors and omissions and liability insurance? YES

Have you ever been convicted of a felony? YES

If YES, please explain: __________________________________________________________________________________________________

_____________________________________________________________________________________________________________________

10.

Are you willing to perform vocational evaluations at a location convenient to the claimant’s residence? YES

If so, what are your estimated fees? _______________________________________________________________________________________

I declare under PENALTY OF PERJURY that the statements contained herein are true and correct to the best of my knowledge and belief. I authorize

all associations, organizations and State and Federal agencies to release to the Court of Existing Claims all relevant documents and information that

may be requested in the investigation of this application. I hereby certify that my certification as a rehabilitation counselor is in good standing. I

agree to abide by all applicable Statutes and Court Rules.

______________________________________________________________________

_____________________________

SIGNATURE

C. 02/01/2014