Request For Accommodations By Persons With Disabilities {DWC 5}

DWC Form 5 - REQUEST FOR ACCOMMODATION BY -PERSONS WITH DISABILITIES. This form is used to request reasonable accommodations for participation in proceedings before the California Division of Workers’ Compensation or Workers’ Compensation Appeals Board. The form collects the requester’s name, contact information, case number, date and location where the accommodation is needed, and a description of the impairment or disability. It also requires the requester to specify the accommodation sought and explain how it will assist with access or participation. Office-use fields allow DWC staff to document whether the accommodation was provided, used, and effective. www.FormsWorkflow.com