Request For Accommodation By Persons With Disabilities
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STATE OF CALIFORNIA
DEPARTMENT OF INDUSTRIAL RELATIONS
DIVISION OF WORKERS’ COMPENSATION
REQUEST FOR ACCOMMODATION BY
PERSONS WITH DISABILITIES
1. Name:
Telephone Number:
2. Mailing Address:
3. Email Address:
4. Person making request is:
Applicant
Attorney
Witness
Other:
5. WCAB/DWC Case No. and Unit (if applicable):
6. Date Accommodation Needed:
7. Location of Accommodation:
8. Specify impairment(s) or disability(ies) for which an accommodation is needed:
9. State accommodation being requested and how it accommodates the impairment/disability:
Date:
(SIGNATURE OF FORM FILLER)
(NAME OF FORM FILLER)
FOR OFFICE USE ONLY
Accommodation Provided? Y N
Accommodation Used? Y N Date Provided____________________
Accommodation effective? Y N
If not, why not? _____________________________________________
__________________________________________________________________________________________________
Other comments: __________________________________________________________________________________
__________________________________________________________________________________________________
Name and Signature _________________________________________________________________________________
DWC Form 5 (Revised 9/29/09)
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Parent category: Legal