Minnesota R 20 Template

Minnesota R 20 Template

The Minnesota R-20 form is an official document designed for individuals applying for approval and registration as a Qualified Rehabilitation Consultant Intern in the state of Minnesota. Managed by the Department of Labor and Industry, this form serves as a starting point for those stepping into the field of rehabilitation consultancy by requiring meticulous provision of personal data, educational background, employment history, and other relevant qualifications. Before embarking on your journey to becoming a Qualified Rehabilitation Consultant Intern, ensure you have accurately completed the Minnesota R-20 form by clicking the button below.

Make This Minnesota R 20 Now

The Minnesota R-20 form serves as a critical step for individuals aiming to establish themselves within the specialized field of rehabilitation consulting in the state of Minnesota. Managed by the Department of Labor and Industry’s Financial Services, the form is essentially an application for approval and registration as a Qualified Rehabilitation Consultant Intern. This application process is not only a regulatory requirement but also a foundational element for those entering this vital sector, ensuring that applicants meet specific educational, experiential, and ethical standards before embarking on their professional journey. Moreover, the form prompts applicants to provide comprehensive personal data, details of professional licensure, certifications or registrations they hold, and information about the Qualified Rehabilitation Consultant under whose supervision they will work. It also includes a requirement for an application fee, alongside questions pertaining to language skills, including proficiency in foreign languages or sign language, and a detailed employment history to support the candidate’s suitability for this role. Significantly, this document underscores the commitment of the applicant to adhere to the statutes, rules, and orders governing the profession in Minnesota, highlighting the serious responsibility individuals take on when entering this field.

Minnesota R 20 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.

File Specifics

Fact Detail
Purpose of the R-20 Form This form is used to apply for approval and registration as a Qualified Rehabilitation Consultant Intern in Minnesota.
Governing Laws The application process is governed by the rules set forth under Minn. Rules 5220.1400, particularly subparts 3a and 5, as well as any other related statutes and orders by the Commissioner of the Department of Labor and Industry.
Application Requirements Candidates must provide personal data, education history, professional licensure, certification or registration details (if applicable), employer information, a detailed employment history, and a check or money order for $110.00 for the application fee.
Special Provisions Applicants are required to be full-time residents of Minnesota or live no more than 100 miles by road from the Minnesota border. They must also agree to notify the Workers’ Compensation Division of any change in employment status and ensure proper case reassignment if necessary.

Guide to Using Minnesota R 20

To embark on a career as a Qualified Rehabilitation Consultant Intern in Minnesota, one must navigate through the R-20 application process for approval and registration meticulously. The process begins with the careful completion of the R-20 form, which is a crucial step in securing a position in this field. Following are the step-by-step instructions to efficiently fill out this form, ensuring that all information is accurately represented and complete.

  1. At the top of the R-20 form, enter your full name (last, first, middle) in the designated space.
  2. Provide your residential address, including your city, state, and zip code where indicated.
  3. Next, write down the name, address (employer’s mailing address), city, state, and zip code of your prospective employer.
  4. Include your home phone number and business phone number in the respective fields.
  5. Answer whether you hold any professional licensure, certification, or registration (e.g., CRC, CDMS) by checking the appropriate box. If yes, list the type of certification and attach a copy as instructed.
  6. Write the name of the Qualified Rehabilitation Consultant (QRC) under whose supervision you will be working.
  7. Enclose a check or money order for $110.00 payable to the Commissioner of the Department of Labor and Industry, including required surcharges as noted in the form instructions.
  8. Indicate whether you speak or write any foreign language and provide details, including the number of years, if applicable.
  9. State whether you are able to communicate using sign language by checking the corresponding box.
  10. If you have previously applied for registration as a QRC/Intern or a Registered Rehabilitation Vendor in Minnesota, mark the appropriate response and provide the date(s) if applicable.
  11. Under the education data section, attach official transcripts of all relevant postsecondary education and list each school’s name, city/state, dates attended from/to, and degree or highest grade completed.
  12. Attach a detailed description of your employment history, starting with the most recent job. Include employer name, phone number, immediate supervisor’s name, address, dates employed from and to, city, state, zip code, job title, and duties performed.
  13. List or attach any other information that may be pertinent to your registration, such as honors or peer recognition.
  14. Read the declaration statements at the end of the application carefully. Sign and date the form, affirming that the information you provided is accurate and that you agree to be bound by all relevant statutes, rules, and orders.
  15. Ensure that both the applicant’s and supervisor’s signatures are notarized where required, with listed commission expiration dates.

Once you have completed the R-20 form following these detailed instructions, the journey towards becoming a recognized Qualified Rehabilitation Consultant Intern in Minnesota moves forward. Your application, along with the attached documentation and fee, should be sent to the Department's Financial Services Section at the address noted at the beginning of your application packet. Successful submission of your application marks a pivotal step towards gaining approval and registration, drawing you closer to beginning your role in this significant field.

Crucial Questions on This Form

  1. What is the Minnesota R-20 form used for?

    The Minnesota R-20 form is designed for individuals applying to become Qualified Rehabilitation Consultant Interns. This application is crucial for those seeking approval and registration under the jurisdiction of the Minnesota Department of Labor and Industry. It gathers personal and educational data, and verifies professional credentials necessary for the registration process.

  2. Who needs to submit the R-20 form in Minnesota?

    Any individual aiming to start their career as a Qualified Rehabilitation Consultant Intern in Minnesota must submit the R-20 form. This applies to professionals who have yet to gain full certification as Qualified Rehabilitation Consultants and are looking to undergo supervised practice.

  3. What information is required on the R-20 form?

    Applicants must provide a range of information, including personal details, prospective employment information, educational background, and employment history. Additionally, the form requires details on any professional licensure, certification, or registration held by the applicant, supervision plans, and any foreign languages spoken or the ability to communicate in sign language.

  4. Is there a fee associated with submitting the Minnesota R-20 form?

    Yes, applicants must enclose a check or money order for $110.00 payable to the Commissioner of the Department of Labor and Industry along with their application. This fee includes a 10% surcharge as mandated by state law.

  5. What documentation must be attached to the R-20 form upon submission?

    • Copies of any license, certification, or registration relevant to the profession.
    • Official transcripts of all pertinent postsecondary education.
    • A detailed supervision plan as required by Minn. Rules 5220.1400, subp. 3a.
    • A list or additional sheet detailing any continuing education or other pertinent information to the registration.

  6. How does one submit the R-20 form and the associated fees?

    The completed R-20 form, along with the necessary fees and attachments, should be sent to the Department of Labor and Industry’s Financial Services Section at the address provided on the form. Specific attention should be given to ensure that all paperwork is complete and accurate before submission to avoid delays in the approval process.

  7. Can the R-20 form be submitted electronically?

    The text provided does not specify an electronic submission option. Therefore, it is implied that the form, along with the required documents and fees, should be submitted via mail to the indicated address of the Department of Labor and Industry’s Financial Services Section.

  8. What are the consequences of omitting information or misrepresenting details on the R-20 form?

    Omissions or misrepresentations on the R-20 form may result in rejection or revocation of the registration. It is imperative that applicants provide accurate and complete information to ensure the integrity of the registration process and adherence to professional standards.

  9. What steps should an applicant take if there is a change in employment status after submitting the R-20 form?

    Applicants are required to notify the Workers’ Compensation Division of the Department of Labor and Industry about any employment status changes. This includes providing information about case reassignment to all relevant parties, pending approval from the Commissioner of Labor and Industry, to maintain transparency and continuity in rehabilitation consulting.

Common mistakes

When filling out the Minnesota R-20 form for the approval and registration of a Qualified Rehabilitation Consultant Intern, individuals commonly make several mistakes. It's important to approach this document with attention to detail and completeness to ensure a smooth application process. Below are ten common errors to avoid:

  1. Failing to print or type clearly, which can cause misunderstandings or processing delays.
  2. Omitting the attachment of license/certification/registration when indicating possession of a professional licensure, certification, or registration, which is critical for validating your qualifications.
  3. Not enclosing the required fee of $110.00 payable to the Commissioner of the Department of Labor and Industry. It's essential to include the check or money order with the application packet.
  4. Overlooking the need to attach official transcripts of all pertinent postsecondary education, a requirement that directly supports your application by showcasing your educational background.
  5. Forgetting to detail continuing education within the past 2 months that pertains to this registration, which is important for demonstrating ongoing professional development.
  6. Omitting the plan of supervision from the QRC supervisor, which is necessary to fulfill the Minn. Rules 5220.1400, subp. 3a requirement.
  7. Providing incomplete employment history, including jobs, durations, and duties. A comprehensive work history is essential for establishing your experience and competence in the field.
  8. Leaving out information on foreign language skills or the ability to communicate in sign language, if applicable, which could enhance your application by illustrating additional competencies.
  9. Not updating the Workers’ Compensation Division of any change in employment status, which is crucial for maintaining accurate records and ensuring compliance.
  10. Failure to confirm full-time residency in Minnesota or living within 100 miles by road from the Minnesota border, as required for eligibility.

By avoiding these common mistakes, applicants can enhance the quality and accuracy of their R-20 Application, leading to a smoother approval process for becoming a Qualified Rehabilitation Consultant Intern in Minnesota.

Documents used along the form

When endeavoring to become a Qualified Rehabilitation Consultant Intern in Minnesota, the R-20 Application is just the starting point. Accompanying this essential form, there are several other documents and forms that play a pivotal role in ensuring your application process is thorough and compliant with the Minnesota Department of Labor and Industry's requirements. Let's delve into some of these significant documents that you'll likely need to gather:

  1. Copy of Professional License/Certification/Registration: If you have any professional licensure, such as CRC (Certified Rehabilitation Counselor) or CDMS (Certified Disability Management Specialist), you must include a copy with your application to prove your qualifications.
  2. Official Transcripts: These provide verification of your postsecondary education, detailing your academic history and achievements. They must be official transcripts sent directly from the educational institutions you attended.
  3. Plan of Supervision: This document, crafted by your QRC supervisor, outlines how your internship will be supervised in accordance with Minn. Rules 5220.1400, subp. 3a. It's essential for ensuring that your training meets the regulatory standards.
  4. Continuing Education Documentation: Any recent continuing education courses relevant to the field of rehabilitation counseling should be documented. This includes dates, course titles, and institutions or organizations that provided the training.
  5. Employment History Documentation: A detailed account of your work history, particularly roles relevant to rehabilitation and counseling, is necessary. It should include employer names, dates of employment, job titles, and descriptions of your duties.
  6. Letters of Reference: While not explicitly mentioned in the application instructions, letters of reference from professionals in your field can bolster your application, showcasing your expertise and commitment to rehabilitation consulting.
  7. Personal Statement: A written statement by the applicant can be valuable, outlining your motivation for becoming a Qualified Rehabilitation Consultant Intern and your career objectives.
  8. Proof of Minnesota Residency: Since the application stipulates that you must be a full-time resident of Minnesota or live no more than 100 miles from the Minnesota border, a document proving your residency, such as a driver’s license or utility bill, might be requested.

Navigating the application process for becoming a Qualified Rehabilitation Consultant Intern involves more than just filling out the R-20 Application. It requires careful preparation of several additional forms and documents that collectively paint a comprehensive picture of your qualifications, experience, and readiness for this role. Gathering these materials meticulously will help ensure your application process proceeds smoothly and positions you strongly for success in the field of rehabilitation consulting.

Similar forms

The Minnesota R-20 form is a document used for individuals applying for approval and registration as a Qualified Rehabilitation Consultant Intern. It requires applicants to provide personal data, professional licensure information, supervisor details, a fee, language skills, and a history of education and employment. This process is somewhat reminiscent of the application process for State Professional License Applications in various occupations, such as medical practitioners, engineers, and lawyers. State Professional License Applications also necessitate personal information, proof of educational attainment, professional credentials, and often a fee. Both sets of documents are integral to ensuring that candidates meet specific qualifications and standards before being granted permission to practice in their respective fields.

Similarly, the Employment Application forms that many businesses and organizations use when hiring new employees bear resemblance to the R-20 form. These employment forms generally ask for candidate's personal information, educational background, and employment history to help employers evaluate if applicants fit the job requirements. While the focus isn't on licensure, both forms are used to ascertain the qualifications of the applicant and ensure a good match between the applicant's skills and the job or role in question.

The process outlined by the R-20 form also shares commonalities with College or University Application forms, which also require a detailed accounting of an applicant's personal information, educational background, and sometimes previous job experiences. These educational applications often require transcripts, like the R-20 form, and might ask for proof of qualifications or certifications relevant to the field of study. Although serving different sectors, both types of applications are crucial steps for individuals seeking to advance their careers or professional standing through education or certification.

Grant Application forms used by many non-profits, educational institutions, and government agencies to distribute funding for various projects also have parallels with the R-20 form. These forms require detailed information about the applicant, an outline of the project or purpose for the fund, and often evidence of qualification or capability to manage and successfully complete the project. Similarly to the R-20 form, grant applications ensure that funds are distributed to candidates or projects that meet particular criteria and are capable of fulfilling the objectives outlined in their proposal.

Lastly, the IRS Form W-9, Request for Taxpayer Identification Number and Certification, although primarily a tax document, shares the need for accurate personal or professional information with the R-20 form. The W-9 form is used by individuals and entities to provide their Taxpayer Identification Number to entities that will pay them income during the tax year. It requires the filer's name, address, and tax identification details, similar to how the R-20 form gathers applicant's personal and professional licensure information for registration and approval purposes. While serving different functions, both are essential for regulatory compliance in their respective fields.

Dos and Don'ts

When approaching the task of filling out the Minnesota R 20 form, it's vital to proceed with both clarity and caution. This form, essential for those seeking approval and registration as a Qualified Rehabilitation Consultant Intern, requires precise and comprehensive input. Here’s a guide to help ensure your submission is both accurate and complete.

Do's when filling out the Minnesota R 20 form:

  1. Print or type clearly: It's important to ensure all information is readable. This avoids any potential misunderstandings or delays in the processing of your application.
  2. Attach all required documents: From professional licenses and certifications to official transcripts of your postsecondary education, ensuring you have all necessary attachments is crucial.
  3. Detail your employment history: The form asks you to describe your work history in detail, including job titles and duties. This is not just a formality but a necessary step to showcase your experience and qualifications.
  4. Sign and date the form: Your signature certifies that the information provided is accurate and truthful. It also indicates your agreement to abide by all pertinent statutes, rules, and orders.
  5. Check for completeness: Before submitting the form, review each section to ensure no required information is missing. This includes checking that all questions have been answered correctly.
  6. Follow submission instructions: Make sure to send the form and any accompanying documents and fees to the correct address provided by the Department’s Financial Services Section.

Don'ts when filling out the Minnesota R 20 form:

  1. Leave sections blank: Unanswered questions can lead to delays in processing your application. If a section does not apply to you, consider writing 'N/A' (not applicable) where appropriate.
  2. Forget to attach the supervision plan: If you are applying to work under the supervision of a Qualified Rehabilitation Consultant (QRC), you must attach a supervision plan that meets specific requirements outlined in the instructions.
  3. Omit payment for the application fee: The form specifies that a check or money order for the application fee must be enclosed with your submission. Failure to do so could result in your application not being processed.
  4. Use outdated information: Ensure that all the data, including personal contact details and employment history, is current and accurate.
  5. Submit unofficial transcripts: The form requires official transcripts of all pertinent postsecondary education. Submitting unofficial copies could invalidate your application.
  6. Overlook notary requirements: For certain sections, not only does the applicant need to sign, but these signatures also need to be notarized. Skipping this step can lead to an incomplete application process.

Adhering to these guidelines not only streamlines the application process but also displays your attention to detail and commitment to professionalism. Taking the time to carefully review and complete the Minnesota R 20 form paves the way for a successful submission.

Misconceptions

Many people have misconceptions about the Minnesota R-20 form, which is crucial for those seeking registration as a Qualified Rehabilitation Consultant Intern in Minnesota. Understanding these misconceptions can help applicants navigate the process more smoothly.

  • It's just a simple form. Contrary to what some might think, the Minnesota R-20 form is not just a "fill-in-the-blank" document. It requires detailed personal data, educational background, employment history, and specific licensures or certifications. Additionally, a plan of supervision and supporting documents, such as official transcripts, must be attached.

  • Any type of licensure or certification is acceptable. This is not the case. The form specifically asks if the applicant holds a professional licensure, certification, or registration in certain fields, such as CRC or CDMS. Only relevant and approved certifications are considered during the application process.

  • You can skip the fee if you're applying for an internship. Every applicant, regardless of their status or intention, needs to enclose a check or money order for $110.00 payable to the Commissioner of the Department of Labor and Industry. This fee includes a mandatory surcharge and is crucial for the application's processing.

  • Language skills are not important. On the contrary, the form enquires about the applicant's ability to speak or write any foreign languages, as well as their capacity to communicate with the deaf in sign language. These skills can be particularly important in diverse communities and thus are relevant to the application.

  • If you've applied before, you don't need to mention it. Incorrect. The form explicitly asks if the applicant has previously applied for registration as a QRC/Intern or a Registered Rehabilitation Vendor in Minnesota. Full disclosure of past applications is required, demonstrating transparency and completeness of the application.

  • Out-of-state residents cannot apply. While the form does require applicants to certify that they are a full-time resident of Minnesota, it also allows for those who live no more than 100 miles by road from the Minnesota border to apply. This detail is particularly important for those who live near state lines and wish to work in Minnesota.

Understanding these aspects of the Minnesota R-20 form can significantly impact the success of an application. Applicants should thoroughly review and accurately complete every section of the form to avoid delays or rejection of their application.

Key takeaways

When filling out the Minnesota R-20 form for the registration of Qualified Rehabilitation Consultant Interns, it is essential to provide accurate and thorough information. Below are six key takeaways to assist applicants in this process:

  • Complete Personal and Employment Data: Ensure to PRINT or TYPE your personal data accurately, including your full name, residence address, contact information, and employment details. This information is crucial for your application to be processed efficiently.
  • Professional Certification: If you hold any professional licensure, certification, or registration, you must indicate this on the form and attach a copy of the related documents. This is important for verifying your qualifications for the role.
  • Application Fee: The form requires enclosing a check or money order for $110.00 payable to the Commissioner of the Department of Labor and Industry. This fee includes a 10% surcharge and is essential for your application to be considered.
  • Education Verification: Attach official transcripts of all pertinent postsecondary education. This step is crucial for the assessment of your educational background in relation to the qualification criteria for a Qualified Rehabilitation Consultant Intern.
  • Supervision Plan Requirement: If applying for an internship, it is necessary to attach a supervision plan as required by Minn. Rules 5220.1400, subp. 3a. This plan should address all the requirements of this subsection and be attached to your application.
  • Declaration and Authorization: By signing the application, you authorize the Workers’ Compensation Division, Department of Labor and Industry, to make any necessary investigation of your application and supporting documents. It's also a declaration that you agree to abide by all statutes, rules, and orders, with the understanding that any violation may lead to the revocation of registration.

Being diligent in preparing your application, including gathering and submitting all required documents, adhering to the guidelines, and correctly filling out the Minnesota R-20 form, will streamline the approval process. Remember, attention to detail and accuracy is key in creating a strong application for the position of a Qualified Rehabilitation Consultant Intern.

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