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Supplemental Job Displacement Nontransferable Training Voucher Form

If an injured worker is not accommodated and returned to work by his or her employer after an injury, then the injured worker can qualify for this return to work assistance benefit.  This Supplemental Job Displacement benefit, also referred to as a "voucher," is paid at either $4,000, $6,000, $8000, or $10,000 depending on the level of final permanent disability rating per Labor Code Section 4658.5.  (click here for table showing this info – and the Labor Code Section)   An injured worker cannot qualify and apply for this benefit until there has been a final determination of the percentage of permanent disability.  This form is used to request the voucher.  This form can be obtained here (link to form on GEK website) or requested from the claims examiner.  This form only applies to injuries that occur between January 1, 2004 through December 31, 2012.   This voucher may be used for the payment of tuition, fees, books, and other expenses required by a state approved or accredited school that you enroll in for the purpose of education related retraining or skill enhancement, or both. 

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Supplmenetal Job Displacement Non-Transferable Voucher Form For Injuries Occurring on or After 1/1/13 DWC - AD 10133.32

If an injured worker is not accommodated and returned to work by his or her employer after an injury, then the injured worker can qualify for this return to work assistance benefit.  For injuries after 1/1/13, this form may be used to obtain a supplemental job displacement non-transferrable $6,000 voucher for education-related retraining and/or skill enhancement. It can be used to pay for education, counseling and/or training services, computer equipment and other supplies. You can take this voucher to a California public school or to a state-certified provider on the Eligible Training Provider List, at http://etpl.edd.ca.gov and the school will be directly reimbursed upon receipt of a documented invoice by the claims examiner. You can also present this voucher to a counselor, which can be selected from the list on the Division of Workers' Compensation's ("DWC") website at: http://www.dir.ca.gov/dwc/SJDB/VRTWC_list.pdf. Further details on how the voucher may be applied is included in the cover sheet to this form and may be found in Labor Code Section 4658.7. (link to this section)

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