Form 10133.35 - State Of California Page 2
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4POSITION REQUIREMENTS
Actual job title:
Per hour
Week
Month
Year
Wages: $
Is salary of regular/modified/alternative work the same as pre-injury job?
Yes
No
No
Yes
Is salary of regular/modified/alternative work at least 85% of pre-injury job?
No
Is job expected to last at least 12 months?
Yes
Is the job a regular position required by the employer's business?
No
Yes
Work location:
Same as Pre-Injury Position
If the job offered is at a different location than the job you held at the time of your injury, and you believe the commuting
distance to this job from the residence where you lived at the time of your injury is not reasonable, you may object to the job offer
as not being within a reasonable commuting distance.
You may also waive this commuting distance requirement. You will be considered to have waived this requirement if you
accept the above offer of work or do not reject the offer within twenty calendar days of receipt of this notice. The employee
should keep a copy of this form for his or her records.
I accept the offer and waive any right to object to the job location or shift as not being within a reasonable commuting
distance from the residence where I lived at the time of my injury.
The shift time is
-
Position is for a different shift.
(Start Time)
(End Time)
Duties required of the position:
Description of activities to be performed (if not stated in job description):
DWC-AD form 10133.35 (SJDB) Eff: 1/1/14 - Page 2 of 4
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