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Request For Approval Of Training Program By Vocational Rehabilitation Counselor 4619 - Oregon

Request For Approval Of Training Program By Vocational Rehabilitation Counselor Form. This is a Oregon form and can be used in Vocational Rehabilitation Workers Comp .
 Fillable pdf Last Modified 4/14/2010
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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: X 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 Program not approved for CEUs Rebecca Folz, Vocational Consultant Date Rehabilitation Review Unit Reemployment and Dispute Resolution Services Section Workers Compensation Division 350 Winter Street NE PO Box 14480 Salem, OR 97309-0405 (503) 947-7797/FAX: (503) 947-7794 440-4619 (10/03/DCBS/WCD/WEB)
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