Dwc Form 156 – Fill Out and Use This PDF

PROSPECTIVE EMPLOYMENT AUTHORIZATION AND CERTIFICATION

Please carefully read the instructions on the reverse side before submitting this form. Incorrect/incomplete forms will be returned without action.

I understand that the Texas Workers' Compensation Act provides for the release of certain prior work related injury information to prospective Texas employers who carry workers' compensation insurance if the employer obtains my written authorization before making a request for that information. I also understand that if this employer is covered by the Americans With Disabilities Act, my prior work related injury claim information may be released only if the indicated employer has properly completed and certified the information on this form. Prospective employers filing valid requests will be provided with a report on prior work related injury claims only if an applicant has made two or more general injury claims in the preceding five years. I hereby authorize release of information permitted by law on my work related injuries to the prospective employer named below.

Job Applicant's Signature _______________________________________________________ Date _________________________________

SWORN AND SUBSCRIBED TO BEFORE ME BY THE SAID _________________________________________ (Print Job Applicant's Name)

ON THIS _____________________________ DAY OF ______________________________________, YEAR _______________ .

I am a prospective Texas employer who has workers' compensation insurance. I am entitled to receive prior injury information concerning this job applicant under the Texas Workers' Compensation Act, Texas Labor Code, Section 402.087. I am not prohibited from receiving this information under the Americans With Disabilities Act of 1990, 42 U.S.C. §12101 et. seq. because:

(Employer Must Check One):

I am a Texas employer who is not covered by the Americans With Disabilities Act of 1990. (The Americans With Disabilities Act of 1990 defines "employer" as: "a person engaged in an industry affecting commerce who has 15 or more employees for each working day in each of 20 or more calendar weeks in the current or preceding year and any agent of such person").

I am a Texas employer who is covered by the Americans With Disabilities Act of 1990, who is requesting this information prior to hiring the above-named job applicant, but after having made a conditional offer of employment to the above-named applicant. I am requesting this information regarding all post-offer prospective job applicants in this job category, regardless of disability. Information concerning the Americans With Disabilities Act may be obtained by calling 1 (800) 949-4232; TDD 1 (713) 520-5136 or the Texas Commission on Human Rights, (512) 437-3450.

A$2.00 fee is required of the prospective employer per request. Your remittance must be attached. The DWC FORM-156 will be returned without action if payment is not enclosed. Fees are subject to change. Make checks payable to DWC.

I certify that I am an authorized representative of this employer and the statements in Section II of this document are true, complete and correct to the best of my knowledge and belief.

Employer/Representative's Signature__________________________________________________ Date __________________