• Send “Notice of Potential Right to Supplemental Job Displacement Form” (10133.52) to employee within 10 days after the termination of temporary disability (TD).

• Copy applicant attorney
• Copy Defense attorney
• Email the RTW Coordinator and copy the “disabilityadmin” box.
• Attach DWC-AD 10133.53 and DWC-AD 10003
• Provide current work restrictions

Return to Work Coordinator

• Upon receipt of email, determine whether regular, modified, or alternative work is available, after holding a face to face interactive meeting with the employee.
• Within 30 days of termination of temporary disability indemnity (TTD) payments
  • If employee returned to regular work, or if regular work is available, complete the DWC-AD 10003, and email back to the TPA.
• If a modified/alternative position is found for the employee, complete the DWC-AD 10133.53, and email back to the TPA.
• If employee has not been declared Permanent and Stationary (P&S) and you have placed the employee on a transitional assignment, note on the 10133.53 the following language:  “Current assignment is being provided on a temporary basis and the need for permanent job modification or return to regular duties will be re-evaluated upon provision of final work restrictions by the treating physician”

TPA

• Sendthe completed DWC-AD1003 or DWC-AD 10133.53 and “Request forDispute Resolution Before the Administrative Director.” (Form DWC-AD10133.55)to the employee (employee has 30 days to accept or reject the offer).

• Copy applicant attorney
• Copy defense attorney
• Email the RTW Coordinator and copy the “disabilityadmin” box.

• Evaluate permanent disability payment rate for 15% increase or decrease of P.D. payments, if applicable.
• At the end of the 30 days, forward the completed copy of the DWC-AD 10003 or DWC-AD 10133.53 signed or unsigned by the employee to the Administrative Director of the DWC.
• Monitor for DWC-AD 10133.55

TPA

• If no regular, modified, or alternate work was offered; within 25 calendar days from the issuance of an award of permanent disability by the WCAB, send the “Supplemental Job Displacement Nontransferable Training Voucher Form” (DWC-AD 10133.57) to the “eligible” employee.
• Copy applicant attorney
• Copy defense attorney
• Evaluate permanent disability payment rate.