Minnesota Form R 20 PDF Details

In the state of Minnesota, the R-20 Application for Approval and Registration Qualified Rehabilitation Consultant Intern form serves a pivotal role in the realm of workplace rehabilitation. Managed by the Minnesota Department of Labor and Industry, located at 443 Lafayette Road North, St. Paul, MN 55155, this form is a critical step for individuals aspiring to become qualified rehabilitation consultant interns. Applicants are required to provide a comprehensive collection of personal and educational data, including but not limited to their full name, contact information, details regarding their professional licensure or certifications, and the name of the qualified rehabilitation consultant under whose supervision they will operate. Additionally, the form mandates a fee of $110.00, a sum that includes a 10% surcharge mandated by 2009 laws, to be enclosed with the application. The R-20 form further explores the applicant's linguistic capabilities, including proficiency in foreign languages or sign language, and inquires about any previous applications for registration in similar roles within Minnesota. Employment history, with a detailed account of previous job roles, and a list of recent continuing education pertinent to the registration, are also essential components of the application. Prospective employers and the individuals providing supervision are required to sign, agreeing to adhere to all relevant statutes, rules, and orders. The assertion of commitment to notify the Workers’ Compensation Division of any changes in employment status highlights the form's role in ensuring continuous, qualified support for workers in rehabilitation. This document, therefore, not only marks the beginning of an intern's journey in rehabilitation consultancy but also underscores the state's commitment to maintaining high standards of practice in worker rehabilitation services.

QuestionAnswer
Form NameMinnesota Form R 20
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesr20 application reference form r 20

Form Preview Example

Minnesota Department of Labor and Industry Financial Services

443 Lafayette Road North St. Paul, MN 55155 (651) 284-5459 or

1-800-342-5354 (DIAL DLI) www.dli.mn.gov

Please PRINT or TYPE

PERSONAL DATA

R-20

Application for Approval and Registration

Qualified Rehabilitation Consultant Intern

NAME (last, first, middle)

 

 

 

 

 

 

 

ADDRESS (residence)

 

PROSPECTIVE EMPLOYER

 

 

 

 

 

 

CITY

STATE ZIP CODE

EMPLOYER ADDRESS (Your mailing address)

 

 

 

 

HOME PHONE NUMBER

BUSINESS PHONE NUMBER

CITY

STATE ZIP CODE

 

 

 

 

1. Do you hold a professional licensure, certification or registration?

If yes, which certification?

CRC

CDMS Other:

Please attach a copy of any license/certification/registration.

Yes

No

2.Name of Qualified Rehabilitation Consultant (QRC) under whose supervision you will work.

3.Enclose a check or money order for $110.00 payable to the Commissioner of the Department of Labor and Industry. (This includes the 10% surcharge pursuant to 2009 Laws, Chapter 101, Article 2, Section 59.) Send all application documents and fees to the Department’s Financial Services Section at the above address.

4.Do you speak or write any foreign language? If yes, name language and number of years.

Yes

No

5. Are you able to communicate with the deaf in sign language?

Yes

No

6. Have you applied for registration as a QRC/Intern or a Registered Rehabilitation Vendor in Minnesota in the past?

Yes

No

If yes, give date(s)

EDUCATION DATA

ATTACH OFFICIAL TRANSCRIPTS OF ALL PERTINENT POSTSECONDARY EDUCATION

NAME OF SCHOOL

CITY/STATE

DATES ATTENDED

FROMTO

month/year month/year

DEGREE OR HIGHEST GRADE COMPLETED

Attach a list of continuing education within the past 2 months which pertains to this registration.

NOTE TO QRC SUPERVISOR: Please see Minn. Rules 5220.1400, subp. 3a and attach a plan of supervision addressing all of the requirements of this subpart.

MN R-20 (3/12)

over

EMPLOYMENT HISTORY

Describe in DETAIL your work history beginning with your current or most recent job. Attach an additional sheet, if necessary.

EMPLOYER NAME

 

 

PHONE NUMBER

IMMEDIATE SUPERVISOR NAME

 

 

 

 

 

ADDRESS

 

 

DATES (from and to)

 

 

 

 

 

 

CITY

STATE

ZIP CODE

JOB TITLE

 

 

 

 

 

 

Duties:

 

 

 

 

 

 

 

 

 

EMPLOYER NAME

 

 

PHONE NUMBER

IMMEDIATE SUPERVISOR NAME

 

 

 

 

 

ADDRESS

 

 

DATES (from and to)

 

 

 

 

 

 

CITY

STATE

ZIP CODE

JOB TITLE

 

 

 

 

 

 

Duties:

 

 

 

 

 

 

 

 

 

List or attach any other information that may be pertinent to registration (i.e., honors, peer recognition, etc.)

I authorize the Workers’ Compensation Division, Department of Labor and Industry to make any investigation of the application and supporting documents. I understand that any omission or misrepresentation may result in rejection or revocation of registration.

I hereby agree to be bound by all statutes, rules and orders and realize that violations may result in revocation of registration.

Subject to approval of this application I agree to notify the Workers’ Compensation Division, Department of Labor and Industry of any change in my employment status. Given a change in my employment status I will accept the responsibility to notify all parties to the case on which I am the assigned Qualified Rehabilitation Consultant Intern as to whom the reassignment will be made, subject to approval of the Commissioner of Labor and Industry.

I CERTIFY THAT I AM A FULL-TIME RESIDENT OF MINNESOTA, or I live no more than 100 miles by road from the Minnesota border. (Minn. Rules 5220.1400, subp. 5)

APPLICANT SIGNATURE

DATE

NOTARY FOR APPLICANT

MY COMMISSION EXPIRES

I hereby agree to provide the supervision outlined on the attached sheet and as provided by Minn. Rules 5220.1400, subp. 3a.

SUPERVISOR SIGNATURE

DATE

NOTARY FOR SUPERVISOR

MY COMMISSION EXPIRES

This material can be made available in different forms, such as large print, Braille or on a tape. To request, call (651) 284-5459 or 1-800-342-5354/Voice or TDD (651) 297-4198.

How to Edit Minnesota Form R 20 Online for Free

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Step 1: Access the form in our tool by pressing the "Get Form Button" at the top of this webpage.

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When it comes to blanks of this particular document, here's what you need to know:

1. The Minnesota Form R 20 needs certain details to be typed in. Be sure that the following blanks are finalized:

Minnesota Form R 20 conclusion process described (portion 1)

2. Your next step is usually to complete the next few blank fields: Do you speak or write any foreign, Yes, Are you able to communicate with, Yes, Have you applied for registration, If yes give dates, Yes, EDUCATION DATA, ATTACH OFFICIAL TRANSCRIPTS OF ALL, NAME OF SCHOOL, CITYSTATE, DATES ATTENDED, FROM monthyear, monthyear, and DEGREE OR HIGHEST GRADE COMPLETED.

Minnesota Form R 20 completion process explained (step 2)

3. This next section is focused on Attach a list of continuing, and over - fill in all of these empty form fields.

Filling out section 3 of Minnesota Form R 20

You can easily make a mistake while completing the Attach a list of continuing, and so you'll want to look again prior to when you finalize the form.

4. Filling out EMPLOYMENT HISTORY Describe in, PHONE NUMBER, ADDRESS, DATES from and to, CITY, STATE ZIP CODE, JOB TITLE, Duties, EMPLOYER NAME, ADDRESS, PHONE NUMBER, IMMEDIATE SUPERVISOR NAME, DATES from and to, CITY, and STATE ZIP CODE is key in this fourth step - don't forget to be patient and take a close look at every blank!

The right way to fill out Minnesota Form R 20 part 4

Step 3: Spell-check what you have entered into the form fields and hit the "Done" button. Sign up with FormsPal today and immediately gain access to Minnesota Form R 20, set for download. All changes made by you are saved , allowing you to customize the form at a later point if necessary. At FormsPal, we aim to guarantee that all of your details are stored secure.

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