Webin completing this form, the employee may contact the Information and Assistance Officer at the Division of Workers' Compensation. The phone number can be found in the State Government section of the phone book. EMPLOYEE NAME: (LAST) (FIRST) (M.I.) CLAIM#: EMPLOYER NAME: JOB ADDRESS: JOB TITLE: HRS. WORKED PER DAY: HRS. … WebForm [DWC-AD 10133.35 “Notice of Offer of Work for Injuries Occurring On or After 1/1/13.”] §10133.36. Form [DWC-AD 10133.36 “Physician’s Return-to-Work & Voucher Report.”] § 10133.51. Notice of Potential Right to Supplemental Job Displacement Benefit. § 10133.52. Form [DWC-AD "Notice of Potential Right to Supplemental Job Displacement

DESCRIPTION OF EMPLOYEE

WebAgree in part. Form DWC – AD 10133.36’s instructions discuss who is responsible for filling out the form. DWC-AD 10133.36 has been amended: “The physician must be either the primary treating physician, a Qualified Medical Evaluator, or the Agreed Medical Evaluator.” Form DWC AD 10133.36 Commenter suggests the following revisions: WebCalifornia Workers’ Compensation Institute 1111 Broadway Suite 2350, Oakland, CA 94607 • Tel: (510) 251-9470 • Fax: (510) 251-9485 March 19, 2013 ... Section 10133.33 Form [DWC-AD 10133.33 “Description of Employee’s Job Duties Form”] Prior to any medical evaluation declaring the employee permanent and stationary, the how to spell tocher

Bradford & Barthel, LLP

WebDWC AD 10133.36 Freeman Rehabilitation Services Debbie Freeman P.O. Box 370, San Carlos CA 94070 Phone: 650-595-4447 ~ Fax: 866-804-0574 [email protected] Physician’s Return-to-Work & Voucher report For dates of injuries post 1/1/13 physicians are required to complete a Physician’s … WebDivision of Workers' Compensation Subchapter 1.5. Injuries on or After January 1, 1990 ... §10133.35 [DWC-AD 10133.36 Form [DWC-AD 10133.36 “Physician's Return-to-Work … WebDWC - AD 10133.33. I. NSTRUCTIONS: This form shall be developed jointly by the employer and employee and is intended to describe the ... DWC AD 10133.33 (SJDB) Eff: 1/2013 Page 1 of 2. 2. Please indicate the daily Lifting and Carrying requirements of the job: Indicate the height the object is lifted from floor, table or rdw tots fifa 22