GOLDEN STATE|CONSULTANTS

SUPPLEMENTAL JOB DISPLACEMENT 

NON-TRANSFERABLE VOUCHER FORM 

FOR INJURIES OCCURRING ON OR AFTER 1/1/13 

DWC - AD 10133.32

 

 

The 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.

 

State-certified providers are available to assist you with your retraining. or you can go to an approved school which 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. 

 

This voucher may be applied to any of the following expenses at the choice of the injured employee: 

 

(1) Education-related retraining or skill enhancement, or both, at a California public school or with a provider that is certified and on the Eligible Training Provider List, including payment of tuition, fees, books, and other expenses required by the school for retraining or skill enhancement. 

 

(2) Occupational licensing or professional certification fees, related examination fees, and examination preparation course fees. 

 

(3) The services of licensed placement agencies, vocational or return-to-work counseling, and résumé preparation, all up to a combined limit of $600. 

 

(4) Tools required by a training or educational program in which the employee is enrolled. 

 

(5) Computer equipment including, but not limited to monitors, software, networking devices, input devices (such as keyboard and mouse), peripherals (such as printers), and tablet computers of up to $1,000 submitted with appropriate documentation (page 4 of this packet). The employer may give the employee the option to obtain computer equipment directly from the employer. The employee shall not be entitled to reimbursement for games or any entertainment media. 

 

(6) Up to $500 as a miscellaneous expense reimbursement or advance, payable upon request (by submitting third page of this packet via email or regular mail) without need for itemized documentation or accounting. 

 

The employee is not entitled to any other voucher payment for transportation, travel expenses, telephone or Internet access, clothing or uniforms, or incidental expenses. 

DWC-AD form 10133.32 (SJDB) Eff: 1/1/14 - 

 

If you pay for eligible expenses, you may be reimbursed for these expenses upon submission of documented receipts to the claims administrator for reimbursement. Reimbursement payments must be made by the claims administrator within 45 calendar days upon receipt of voucher, receipts, and documentation. 

 

If you decide to voluntarily withdraw from a program, you may not be entitled to a full refund of the voucher.  If there is a dispute regarding this voucher, the employee or claims administrator may file Form DWC-AD  10133.55 "Request for Dispute Resolution before the Administrative Director" with the:

                                            Administrative Director, 

                                            Division of Workers' Compensation,                                                                                                 P.O. Box 420603,                                                                                                                                 San Francisco, CA 94142-0603. 

 

If you have a question or need more information, you can contact your employer or the claims administrator. 

 

You can also contact a DWC Information and Assistance ("InA") Officer. Contact information for I&A can be found at: http:www.dir.ca.gov/dwc/ianda.html.