SUPPLEMENTAL 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.