STATE OF CALIFORNIA DEPARTMENT OF INDUSTRIAL RELATIONS DIVISION OF WORKERS' COMPENSATION REQUEST FOR ACCOMMODATION BY PERSONS WITH DISABILITIES 1. Name: 2. Mailing Address: 3. Email Address: 4. Person making request is: Applicant Attorney Witness Other: Telephone Number: 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 effective? Y N Accommodation Used? Y N Date Provided____________________ If not, why not? _____________________________________________ __________________________________________________________________________________________________ Other comments: __________________________________________________________________________________ __________________________________________________________________________________________________ Name and Signature _________________________________________________________________________________ DWC Form 5 (Revised 9/29/09) American LegalNet, Inc. www.FormsWorkFlow.com