Form DWC-AD 10133.57 – Mandatory Form; 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.

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 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.