Form Dwc-Ad 10133.53 - Notice Of Offer Of Modified Or Alternative Work - State Of California Page 3

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Physical requirements for performing work activities (include modifications to usual and customary job):
Name of doctor who approved job restrictions (optional):
Date of report:
MM/DD/YYYY
Date of last payment of Temporary Total Disability:
MM/DD/YYYY
Preparer's Name:
Preparer's Signature:
Date:
MM/DD/YYYY
THIS SECTION TO BE COMPLETED BY EMPLOYEE (All information in this section must be completed)
I accept this offer of Modified or Alternative work.
I reject this offer of Modified or Alternative work and understand that I am not entitled to the Supplemental Job
Displacement Benefit.
I understand that if I voluntarily quit prior to working in this position for 12 months, I may not be entitled to the
Supplemental Job Displacement Benefit.
Signature:
Date:
MM/DD/YYYY
I feel I cannot accept this offer because:
DWC-AD form 10133.53 (SJDB) 11/13 Page 3 of 4

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