Free Request for accommodations by persons with disability - California


File Size: 204.6 kB
Pages: 1
File Format: PDF
State: California
Category: Workers Compensation
Author: Daniela Giomi
Word Count: 85 Words, 652 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.dir.ca.gov/dwc/Form5.pdf

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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)