Dwc Ad Form 10133 53 – Fill Out and Use This PDF

State of California

Division of Workers' Compensation

NOTICE OF OFFER OF MODIFIED OR ALTERNATIVE WORK

FOR INJURIES OCCURRING BETWEEN 1/1/04 - 12/31/12, INCLUSIVE

DWC - AD 10133.53

THIS SECTION COMPLETED BY CLAIMS ADMINISTRATOR (All information in this section must be completed):

Claims Administrator Type: (Please Choose One)

Employer Name

is offering you

				(Employee Name)
the position of a								.
				Job Title
You may contact
concerning this offer. Phone No.:					Date of offer:		Date job starts:
						MM/DD/YYYY				MM/DD/YYYY

Claims Administrator

Claim Number :

NOTICE TO EMPLOYEE (All information in this section must be completed)

Name of employee:

First Name

Last Name

(Choose only one)

a specific injury on

MM/DD/YYYY

a cumulative trauma injury which began on

and ended on

(START DATE: MM/DD/YYYY)

(END DATE: MM/DD/YYYY)

Date offer received:

Date of Birth:

MM/DD/YYYY

MM/DD/YYYY

You have 30 calendar days from receipt to accept or reject the attached offer of modified or alternative work. Regardless of whether you accept or reject this offer, the remainder of your permanent disability payments may be decreased by 15%. However, if you fail to respond in 30 days or reject this job offer, you will not be entitled to the supplemental job displacement benefit unless:

A. You cannot perform the essential functions of the job; or

B. The job is not a regular position lasting at least 12 months; or

C. Wages and compensation offered are less than 85% paid at the time of injury; or

D. The job is beyond a reasonable commuting distance from residence at time of injury.

DWC-AD form 10133.53 (SJDB) Rev: 1/1/14 Page 1 of 4

POSITION REQUIREMENTS (All information in this section must be completed)

Actual job title:

Wages: $

Per hour

Week

Month

Year

Is salary of modified/alternative work the same as pre-injury job?

Yes

No

Is salary of modified/alternative work at least 85% of pre-injury job?

Yes

No

Will job last at least 12 months?

Yes

No

Is the job a regular position required by the employer's business?

Yes

No

Work location:

Duties required of the position:

Description of activities to be performed (if not stated in job description):

DWC-AD form 10133.53 (SJDB) Rev: 1/1/14 Page 2 of 4

Physical requirements for performing work activities (include modifications to usual and customary job):

Name of doctor who approved job restrictions (optional):

Date of report:

MM/DD/YYYY

Date of last payment of Temporary Total Disability:

MM/DD/YYYY

Preparer's Name:

Preparer's Signature:

Date:

MM/DD/YYYY

THIS SECTION TO BE COMPLETED BY EMPLOYEE (All information in this section must be completed)

I accept this offer of Modified or Alternative work.

I reject this offer of Modified or Alternative work and understand that I am not entitled to the Supplemental Job Displacement Benefit.

I understand that if I voluntarily quit prior to working in this position for 12 months, I may not be entitled to the Supplemental Job Displacement Benefit.

Signature:		Date:
			MM/DD/YYYY

I feel I cannot accept this offer because:

DWC-AD form 10133.53 (SJDB) 11/13 Page 3 of 4

NOTICE TO THE PARTIES

If the offer is not accepted or rejected within 30 days of receipt of the offer, the offer is deemed to be rejected by the employee.

If a dispute occurs regarding the above offer or agreement, either party may request the Administrative Director to resolve the dispute by filing a Request for Dispute Resolution (Form DWC-AD 10133.55) with the Administrative Director, Division of Workers' Compensation, P.O. Box 420603, San Francisco, CA 94142-0603.

DWC-AD form 10133.53 (SJDB) Rev: 1/1/14 Page 4 of 4