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STATE OF CALIFORNIA DEPARTMENT OF INDUSTRIAL RELATIONS DIVISION OF WORKERS' COMPENSATION
Case No(s): Applicant v.
Defendant
FORM TO BE KEPT CONFIDENTIAL (if box checked)
REQUEST FOR ACCOMMODATIONS BY PERSONS WITH DISABILITIES
1. Name: 2. Address: 3. Person making request is: Applicant
Telephone Number:
Attorney
Witness
Other:
4. Dates accommodations needed (specify): 5. Impairment necessitating accommodations (specify):
6. Type of accommodations (specify):
7. I request that my identity: Date:
be kept CONFIDENTIAL
NOT be kept CONFIDENTIAL
(TYPE OR PRINT NAME)
(SIGNATURE OF REQUESTOR)
DWC Form 5 (Revised 1/06)