reference manual for the return-to-work guide - Chief Executive ...

REFERENCE MANUAL
FOR
THE RETURN-TO-WORK GUIDE

TABLE OF CONTENTS
Section
1) Day One
Industrialinjury/lllness Reporting Flow Chart
Confidential Health Certificate
County Benefit Information Letter
Medical Management Numbers for Injury Reporting
MegaFlex Supplement Letter
2) Day Two & Three
Accident Investigation Procedure
Family and Medical Leave Overview
Family Care and Medical Leave and Pregnancy Disability Leave
Family and Medical Leave Frequently Asked Questions and Answers
Predesignation
Wage Statement
Work Abilties Questionnaire
Work Hardening Transitional Assignment Agreement
3) Day Seven & Fourteen
Job Description
4) Day Thirty
Alternate Options to Accommodate Work Restrictions/Possible Temporary
Assignments
Modified Options for Specific Body Parts and Possible Work Restrictions
Explanation of Physical Demands
Physician Office Contact and Suggestions for Working with Staff
5) Day Seventy
Modified Work Offer Letter
Notice of Modified or Alternative Work:
RU-94 (For injuries on or after 01/01/94)
DWC-AD 10133.53 (For Injuries on or after 01/01/04)
Notice of Offer of Regular Work (DWC-AD 10003)
Order to Return to Usual and Customary Work
Rules and Regulations on Job Displacement Benefits
Sample Work Restriction Notification Letters (Verbal, Temporary & Permanent)
6) Day Eighty-Four
Americans with Disabilty Act Information
Equal Employment Opportunity for the Disabled Booklet
Comparison of California and Federal Employment Disability Provisions
Disabilty under the Fair Employment & Housing Act Booklet
Enforcement Guidance for Reasonable Accommodation
7) Day Ninety-Four
8) Day One-Hundred-Twenty

Section
9) Six and Nine Months
County Code on Long-Term Disability
Frequently Asked Questions and Answers on Long-Term
Disability
10) Twelve Months
County Code on Leave of Absence
County Code on Leave Donation Program
Post Salary Continuation Supplement Letter
11) Fifteen, Eighteen, Twenty-One, and Twenty- Three-Months
12) Twenty-four Months
Checklist for LACERA Disability
LACERA Salary Supplement Provisions
Government Code regarding Disability Retirement
and Salary Supplement
13) Thirty Months
Civil Service Rule 9.08 on Medical Separation
Guidelines for Documentation of Medical Release
Medical Release/Retirement Plans A through D
Sample Medical Separation Letters
14) Contacts
Contacts within the County of LA
Helpful Internet Links
LACERA
VPA Phone List
Workers' Compensation TPA Phone List
15) Forms
Employee's Report of Accident
Workers' Compensation Claim Form (DWC-1)
Workers' Compensation Employer's Report (5020)
Employee's Statement Declining Medical Treatment
First Alert Form
LDW/RTW Verification Form
Patient Status Report: Physical Injury
Receipt of Employee Packet
Treatment Referral Slip
Treating Physician's Letter
Wage Statement
Weekly Telephone Call Log
Work Hardening Transitional Assignment Agreement Amended
Notice of Offer of Modified or Alternative Work (DWC-AD 10133.53)
Request for Dispute Resolution (DWC-AD 10133.55)
Notice of Offer of Modified or Alternative Work (RU-94)
Supplemental Job Displacement Nontransferable Training Voucher Form

SECTIQ

Complete 5020
This form should be completed by
the injured employee's supervisor
within 24 hrs. of receiving
notification of the injury
INDUSTRIAL INJURY/ILLNESS
REPORTING FLOW CHART
Employee Sustains Work-Related Injury
If Medical Emergency Call 911
DOES INJURED WORKER SEEK MEDICAL TREATMENT *
Provide DWC-1
If signed by EE process
form w/in 24hrs
Call Your Department's Medical
Management Co.:
Corvel
Diversified/Fairissacs
Com .I.Q.
~
Incident Report * *
Supervisor Completes Form
Forward a copy to RTWC
Decline Medical Treatment Card
EE Completes Form
Forward form to RTWC
k Pre - Designated Physician MUST be verified with Human Resources or Personnel
* * Complete Incident Report for all First Aid Incidents

SECTION 3.
The Confidential Health Certificate, including the medical information in Section 2,
is not to be presented or sent to the emplovee's department.
INSTRUCTIONS TO PHYSICIAN/HEALTH CARE PROVIDER AND EMPLOYEE
1. Employee completes Section 1 oHorm, including signing and dating the Authorization.
Employee may retain a copy of the Authorization or request a copy from the
physician/health care provider or Occupational Health Programs.
2. Physician or other health care provider completes Section 2 of form and retains copy.
If employee's condition is of a medical nature, health care provider should give
completed form to employee (as per 3a, below). If condition is of a psychological
nature or involves substance abuse treatment, the physician/health care provider
should mail the form to Occupational Health Programs (as per 3b).
3a. Medical Conditions. If the employee's department is seeking confirmation of
clearance to return to duty, or further clarification regarding work restriction following
an ilness or injury of a medical nature, the employee should take the completed form
to the County contract clinic designated by the employee's department and present it
at the time of the appointment scheduled by the department. The contract clinic wil
provide the employee with certification of the employee's clearance status and the
need for any work restrictions.
3b. Psychological Conditions. For periods of absence involving treatment of
psychological problems, stress, or substance abuse, the health care provider or
employee should mail the completed form 10 days prior to the anticipated date of
return to work to:
Chief of Psychological Services
Occupational Health Programs
3333 Wilshire Blvd., Suite 1000
Los Angeles, CA 90010
Telephone: (213) 738-4200
Upon receiving the completed form, Occupational Health Programs wil call the
a
employee to schedule an appointment for a return-to-work evaluation conducted by
licensed psychologist. Following the appointment, OHP wil notify the employee's
department regarding the employee's clearance status and the need for any work
restrictions.

COUNTY OF LOS ANGELES
CHIEF ADMINISTRATIVE OFFICE
OCCUPATIONAL HEALTH PROGRAMS
CONFIDENTIAL HEALTH CERTIFICATE
NOT TO BE
PRESENTED TO
THE PERSONNEL
OFFICER NOR TO
BECOMEA PART
OF A PERSONNEL
FILE
SECTION 1. DISCLOSURE AUTHORIZATION (TO BE COMPLETED BY EMPLOYEE)
Last Name First Name M.I. Date of Birt Social Securit Number
Home Addres
Departent Wor Addres
Home Phone Numbe
Work Phone & Ex.
Supervisor's Name Supervisor's Phone & Ex.
Health Plan:. Member Number:
AUTHORIZATION: I hereby authorize the health care provider/agency designated below to provide the information
requested in Section 2 of this form, and any additional information as may relate to my capacity to perform my job duties
satisfactorily and without hazard to my health or to the health and safety of others. The records/information for release
shall be those pertaining to my - medical - psychological/psychiatric - substance abuse treatment health care.
Health Care Provider/Agency:
Name
Address
Disclosure is for the following purpose: (a)- at my request; or (b)
I understand that I may refuse to sign this authorization, and that such refusal shall not prevent the designated health care
provider/agency from providing any health care benefis to which i am otherwise entitled.
Disclosure shall be to Occupational Health Programs (OHP), County of Los Angeles, or to one of its contracting medical
groups. Specific limitations that i wish to impose on the lawful and ethical use of the disclosed information shall be
(a) _to be used solely to determine my capacity to return to work with or without restrictions; or (b) the following:
Signer has the right to revoke this authorization at any time, except for action already taken that relied on the authorization. Signer may
revoke the authorization by notifying the above designated health care provider/agency in writing. Unless so revoked, this authorization
will expire one year from the date of my signature, below. A photocopy of this authorization is as valid as the originaL. Occupational
Health Programs, or its contract clinic, shall not further disclose information obtained pursuant to this authorization except by separate
authorization of signer or by order of a court or other lawful authority. Signer shall receive a copy of this authorization.
Signature: Date:

SECTION 2. TO BE COMPLETED BY ATTENDING PHYSICIAN / HEAL THCARE PROVIDER
1. I attended the patient for the present medical problem from MONTH /
/
DAY
YEAR
to /
MONTH - DAY YEAR
2. Has the patient at any time during your attendance for this problem been incapable of performing his/her regular work?
L. Yes l- No If "Yes," the disability extended from / I to I /
MONTH DAY YEAR MONTH DAY YEAR
3. Earliest date patient may return to work
MONTH /
/
~ YEAR
Complete either a of b, below. Please review job description before completing. We believe it is in the employee's best
interest to resume work as soon as possible, even if limited.
a. L. Patient may return to work without restrictions.
b. L. Patient may resume work with the following restriction(s): (specify) Anticipated Duration
4. History:.
5. Findings (including results of special diagnostic tests or procedures):
6. Diagnosis:.
7. Treatment (including surgical):
8. Prognosis:-
i hereby certify that these statements are accurate to the best of my professional opinion and that I am a
Type of Specialist
licensed to practice by the State of
)
State License Number Office Telephone
Date
Print Name Legibly Signature
/

TO:
FROM:
COUNTY BENEFIT INFORMATION
This memo is intended to provide you with practical and basic information about the
resources available to you while you are on disability. It is also intended to support your
speedy recovery and safe return to work.
Disabled or injured employees who are absent from work are required to maintain
regular contact with their supervisor and provide information about the status of their
disability by completing the proper medical certification forms for all continual medically
related absences.
Continuous absences due to illness or injury shall be compensated for sick leave at full
or partial pay, depending on the employees available benefit balance.
Specific information may be obtained from the many resources identified in this letter.
WHAT YOU SHOULD KNOW IF YOU ARE ABSENT BECAUSE OF ILLNESS OR
INJURY
When an ilness or injury requires you to be absent from work, you may have questions
and other concerns regarding the appropriate actions and your responsibilities. To
assist you with these questions and concerns, this memo provides information
associated with disability benefits and Return to Work programs. The types of
programs and the steps required are briefly explained and cross-referenced to guide
you through the information needed. Please be advised that for each program or
benefit, certain eligibility criteria apply.
The following is a list of benefits and programs that are available:
WORKERS' COMPENSATION (WORK RELATED INJURIES/ILLNESSES)
Employees who sustain a work-related injury/illness are entitled to workers'
compensation benefits. Following are the five (5) basic types of benefits:
. Medical Treatment
. Temporary Disability
. Permanent Disability
. Vocational Rehabilitation
. Death Benefit

The type of benefit depends on the nature and severity of the injurylillness.
EMPLOYEE ASSISTANCE PROGRAM
The Employee Assistance Program of Los Angeles County serves the emotional needs
of the employees since 1968. The Employee Assistance Program can help you deal
with such problems as:
. Emotional Stress
. Anxiety
. Marital/Family Discord
. Bereavement/Loss
. Alcohol and/or Drug Dependency
. i nterpersonal Problems
All Employee Assistance Program services are private and confidentiaL.
RETURN TO WORK - INDUSTRIAL AND NON-INDUSTRIAL
The Return to Work Program offers an employee access to transitional duties that are
approved by his/her physician. Please contact your Return to Work Coordinator to
obtain information regarding the transitional return to work program. The Return to
Work Coordinator will ensure that the employee is provided with all the necessary
information regarding benefits and will oversee the employee's return to work.
FAMILY AND MEDICAL LEAVE ACT (FMLA) - PREGNANCY DISABILITY LEAVE
(PDL) - CALIFORNIA FAMILY RIGHTS ACT (CFRA)
The Family and Medical Leave Act of 1993 (FMLA) enables qualifying employees who
are absent from work due to an industrial or non-industrial injury or ilness to be
automatically placed on Pregnancy Disability, Family Leave and California Family
Leave, if the employee has worked at least 1,250 hours in a 12-month period
immediately before the requested leave date and meets the eligibility criteria.
SHORT-TERM DISABILITY PLAN (STD)
This plan is available to MegaFlex participants. STD benefits replace a percentage of
your salary if you become sick or injured and cannot carry out your regular job duties.
Disability can result from ilness or injury at work or at home.
LONG TERM DISABILITY - SURVIVOR BENEFIT PLAN (L TD) OPTIONS
This plan is extended for all general members of the Retirement association with the
exception of Safety members who are not MegaFlex participants. Non-MegaFlex
Safety members may elect coverage under separate Department or Union benefit

programs. The L TD plan is 100% employer paid for Choices, Options, and Flex
participants and for some MegaFlex Plan E participants.
COALITION OF COUNTY UNIONS-LONG TERM DISABILITY BENEFITS (SAFETY)
Long Term Disabilty insurance is a benefit provided to County employees represented
by the Coalition of County Unions. The monthly benefit amount may be reduced by any
other income you received for the disabling condition. Benefits are provided during a
continuous disability, and are payable for the duration of your approved disability up to
age 65, for both work related (industrial) and non-work related (non-industrial) related
disabilities. For additional information regarding this benefit, please contact your
benefits coordinator or Union Representative.
MEDICAL COVERAGE PROCTECTION (L TD HEALTH INSURANCE)
All eligible employees for the County sponsored L TD program may purchase the L TD
medical coverage protection benefit. The L TD Health Insurance plan is designed to
help you continue your medical insurance plan while you are out on disabilty. If you are
approved for L TD benefits, the L TD Health Insurance wil pay 75% of your monthly
medical premium; you wil be responsible for the other 25% of your premium.
NO PAY STATUS - CONTINUATION OF HEALTH CARE BENEFITS
If, for any reason, you are in a no pay status for an entire month, or receive less than
eight (8) hours of pay, or receive pay for less than eight (8) hours of benefits such as
sick or vacation, you are not eligible to receive the County contribution benefit
allowance. If you have not pre-elected the L TD Health Insurance Plan to assist you with
your medical insurance premiums, you are required to pay your insurance premiums in
fulL. You will receive a bil from the County's Benefit Plan Administrator. You may call
the Benefits Hotline at (213) 388-9982 for additional information.
Should your coverage lapse, you are eligible to re-enroll in health benefits upon your
return to work. It will take between 60 and 90 days for reinstatement of your benefits.
PAYROLL DEDUCTIONS
As long as you are receiving a paycheck from the County of Los Angeles, payroll
deductions will continue to be deducted from your paycheck. Once you enter into a no
pay status or your earnings do not cover your deductions, you are required to contact
your creditors to make arrangements to pay these deductions. This includes:
. Health care spending account and dependent care account
. Retirement
. Credit Unions
. Unions
. Any personal designated deductions

LEAVE DONATION (REPRESENTED EMPLOYEES)
To provide assistance to represented employees who have a serious or catastrophic
ilness or injury, or who are absent due to an emergency specifically declared by the
Board of Supervisors, full pay sick leave, vacation hours, overtime, and holiday time
may be transferred from one or more represented employees and donated to another
represented employee on an hour-for-hour basis, upon the request of both the receiving
employee and the transferring employee(s), and upon approval of the receiving
employee's appointing authority or designee under specific conditions.
RELIEF PROGRAMS
Some County Departments and Unions have internal emergency relief or hardship
committees that have been created to assist employees in time of need. For information
please contact your Department Benefit Coordinator or Union Representative.
DISABILITY RETIREMENT
Retirement Plan E members are not eligible to file for a disability retirement.
Members of Retirement Plans A-D are eligible to file for disability retirement at any time.
Once Long Term Disabilty (L TD) has exceeded 24 months employees are required to
file for disability retirement or the department may file/apply for the employee.
The above benefit information is intended to provide you with information. It is not
intended to be a thorough explanation of all benefits available. If you have any
questions regarding the above listed benefits contact your Department's Return to Work
Coordinator, your Human Resource Benefits Coordinator or the appropriate insurance
provider.

MEDICAL MANAGEMENT NUMBERS
CAll IN # FOR 5020's
COMP IQ
(866) 291-7121
CORVEl CORPORATION
(888) 419-0585
FAIR ISAAC
(800) 931-9547

DATE:
COUNTY OF LOS ANGELES
TO: Employee #:
FROM: Return to Work Section
SUBJECT: COMPENSATION PAY FOR MEGA II A (MegaFlex Industrial Accident)
&. STD (Short-Term Disabilty)
MegaFlex participants who are off work with an authorized I/A may supplement their worker's
compensation benefits to equal 100% of their salary. However, a Mega I/A may NOT be supplemented
if STD is also paid on the same day or same period of time, unless the claim status is sent to payroll
retroactively.
If a MegaFlex employee with a compensable industrial injury chooses to supplement their Mega 1/ A
benefits, rather than use STD benefits, the following leave types may be used: non elective leave,
elective leave, previously earned vacation, holiday or accumulated 100% sick.
TO PAYROLL: The above employee sustained an injury on and has been on a medical
leave of absence since . Please allow the employee to use any available time.
Non Elective
Elective
Vacation
Holiday
100% Sick
TO EMPLOYEE: If you elect to supplement your Workers' Compensation benefits, select the order you
wish to use the time and the effective date . Sign below, retain a copy for your file,
give payroll the original, then forward a copy to your supervisor and the return to work unit.
Name (print)
Employee Signature Date
NOTE: You must contact your payroll clerk to verify all useable hours. Usage of your time wil
be continuous until exhausted or you return to work.
*The MegaFlex contribution (used to buy benefits) may only be received for six continuous months
when an employee is off work due to an injury/ilness and receiving County payments for Mega I/A, STD,
or both. Once an employee is not receiving a check from their employer, they must pay 100% of their
benefits unless Long-Term Disabilty Health (LTDH) was purchased in advance of the injury/ilness. If
L TDH was purchased when applying for annual benefits, and the employee is on Long-Term Disabilty,
the County wil pay 75% of the medical expence, and the employee pays for 25%.

SUPERVISORY CHECKLIST FOR NON INDUSTRIAL INJURY RETURN TO WORK
. Ensure that sufficient controls/procedures are in place to expedite reporting to
management/HR any episodes of extended, repeated, or (if known) medically
significant absenteeism.
. Check to see if the employee has filed a Report of Industrial Accident/Injury. If
so, no Occupational Health Program (OHP) based reevaluation/RTW can be
preformed.
. Check to see if the employee has requested or is eligible for FMLA. During the
time the employee is on FMLA, OHP based reevaluation/RTW cannot be
performed.
o If the employee's FMLA certificate is unclear/needs clarification, discuss
with management/HR the need for OHP to seek such clarification from the
medical provider.
o If such clarification is desired, obtain authorization from the employee.
(Note: no additional information may be solicited from the health care
provider beyond what is necessary to clarify the original statement of
medical fitness.)
. If there are no issues of chronic absenteeism, if the current absence is not unduly
lengthy and there are no issues of possible work restrictions which cannot be
accommodated upon the employee's return, the supervisor (within the department's
policy) may accept an employee back to work with just a certification from
the treatment provider.
. If you are unsure of the need for OHP based RTW or reevaluation, request that
management/HR consult with OHP (213-738-2187).
. If it is anticipated that an OHP based RTW evaluation will be necessary the
supervisor should request management/HR to:
o Try to seek clarification directly from the employee's treatment provider
(without the employee's authorization the treatment provider will not be
able to discuss any medical issues but may be wiling to discuss the work
restriction information.)
o Provide the employee with a Confidential Health Certificate and
instructions for completion of the form well in advance of the anticipated
RTW date.
o Obtain OHP approval if the employee declines to participate voluntarily.
o Make an appointment with a medical clinic (for medical conditions) or with
Psychological Services (if this is a known psychological based absence)
for a RTW evaluation. (Note: If the appointment time is delayed past the

date the employee was cleared to return to work by his/her medical
provider, the department may be liable to pay back wages.)
. If the resultant RTW clearance (from the employee's health care provider, from
the medical contract clinic, or from OHP) precludes a return to full duty, the
department must engage the employee in an interactive process.
. If the episode of absenteeism is reflective of a chronic problem or if the employee
is at work (or has returned to work) and there are continuing issues that appear
to be hindering the employee's abilty to perform essential job duties, consider a
formal medical and/or psychological reevaluation through OHP. The supervisor
should make such requests to the department's managementlHR in accordance
with normal departmental procedures/channels. In most cases, department HR
staff will:
o Consult with OHP before proceeding with a formal request.
o Ensure that there is no conflcting workers' compensation claim and no
current FMLA eligibilty.
o Prepare a written request for reevaluation including documentation and
will obtain the employee's concurrence or will request OHP approval to
order the employee.
o If OHP proceeds with a formal reevaluation, the supervisor may be
contacted by OHP staff (or department managementlHR may make such
contact) for additional background information.
o If the OHP reevaluation precludes the employee from working without
restrictions, the department must engage the employee in an interactive
process to consider reasonable accommodation.

SECTIQ

ACCIDENT INVESTIGATION PROCEDURE
Prepared by Chief Administrative Offce, Risk Management Branch
Loss Control and Prevention Section
3333 Wilshire Blvd., Suite 820, Los Angeles, CA 90010
Call (213) 351-5479 for additional information
The purpose of any accident investigation is to determine the cause(s) of the accident,
identify any necessary corrective actions and implement those corrective actions timely.
This applies to employee accidents, accidents involving members of the public, vehicle
accidents (including vehicle propert damage), and losses involving propert.
Gal/OSHA regulations require that all employers have a procedure to investigate
occupational injuries/illnesses. To comply with the regulations, your department's Injury
and Illness Prevention Program (IIPP) lists the accident investigation procedure. Under
the procedure, supervisors are responsible for investigate all occupational accidents.
Why are you doing the investigation?
As a supervisor, you can gather information and conduct the investigation timely. You
possess the most extensive knowledge about the work environment and the personal
background of the affected employees(s). You also possess the greatest familiarity with
the equipment, machines, and materials involved in the accident and know most about
the standard work practices in the area.
You are directly responsible for the health and safety of your employees in addition to
the equipment, machines, and materials in the work area. You can take the most
immediate action to prevent an accident from recurring. You also have the greatest
opportunity to implement corrective actions.
How to conduct an accident investigation?
Assure your employees are trained to notify you promptly about all accidents. If an
accident involves the death or hospitalization of an employee, notify the department
Safety Officer immediately. Gal/OSHA requires departments to report accidents that
involve death or serious injury/illness of an employee. Your department Safety Officer
would determine the applicability of the Gal/OSHA requirement and file appropriate
reports.
Model - Accident Investigation Procedure

i. Gathering Information
The first priority whenever an accident occurs is to deal with the emergency and ensure
that any injuries or ilnesses receive prompt medical attention. The accident
investigation should begin immediately thereafter. Doing so ensures that details of what
occurred will be fresh in people's minds and that witnesses do not influence each other
by talking about the accident. It also minimizes the likelihood that important evidence is
removed before the scene has been inspected.
While conducting an accident investigation, it is important to:
. maintain objectivity throughout the investigation;
. discuss the accident with the injured person, but only after first aid or medical
treatment has been given;
. talk with anyone who witnessed the accident and those familiar with conditions
immediately before and after it occurred;
. check or photograph the accident site and circumstances thoroughly; and
. examine appropriate physical evidence and existing records.
General Interview Techniques
If possible, conduct the interviews at the accident site, where injured employees and
witnesses can recall and point out details. It is prudent to keep the interviews as private
as possible by interviewing one employee/witness at a time. This would prevent
influence from other employees/witnesses.
During the interview, put the interviewee at ease by being courteous and considerate.
Your role is to ask questions, listen carefully and take notes. The use of a tape recorder
should be avoided. If a tape recorder is used, consent of the interviewee must be
obtained.
The employee/witness should be allowed to speak freely with minimum interruptions.
Open-ended questions (e.g., How did the accident happen?) should be asked first.
Closed-ended questions (e.g., Did you see the oil on the floor?) for clarification and
verification should be asked at the end of the interview.
To minimize interruptions, do not make incidental remarks (e.g., Oh, Yeah!),
interpretation (e.g., Are your saying that ...?), or opinion (e.g., I think. . .). Delay
clarifications to the end of the interview.
Interview Injured Employee
If possible, first interview the employee(s) involved in the accident.
avoid assigning blame or discuss disciplinary repercussions.
promise any immunity from disciplinary actions.
During the interview,
Additionally, do not
Ask the employee to provide his/her version of the accident. Repeat the employee's
account when the employee has finished tellng his/her version of the accident. Ask the
"why" questions (e.g., Why were you doing. . . ?) after obtaining all other pertinent
information about the accident. The delay is needed since these questions can make
the employee defensive.
Model - Accident Investigation Procedure

Interview Witnesses and Others
Strive to speak with anyone who witnessed the accident and those familiar with
conditions immediately before and after it occurred. Avoid getting hearsay information.
Ask the witnesses about:
. Where they saw the accident occur
. When they saw it
. Who was involved
. What they saw
For many incidents or accidents, the witnesses would be other employees in the area.
Since these employees are familiar with the equipment, machines, and materials
involved in the incident or accident, it is a good practice to ask them what they think
could be done to prevent a similar accident.
Physical Evidence
Examine the equipment, materials, and/or work environment related to the accident.
Take photographs whenever needed. If there are technical questions, consult with
appropriate experts.
Example 1: if an employee slipped and fell, check:
. floor for damage or slipperiness, and
. ilumination for the area.
Example 2: if an employee hurt his back while carrying boxes, check:
. weight of each box, and
. distance carried.
Existinq Records
Obtain and examine existing records as needed. These records include, but are not
limited to, training records, records on equipment such as work orders, maintenance
logs, and operating manuals.
II. Determine the Causes
After all the information has been gathered and photographs taken, you must determine
the cause(s) of the accident. An accident can usually be attributed to one or more of
the following causes:
A. Unsafe Conditions
1. Equipment related causes (e.g., mechanical failure, defective equipment)
2. Conditions related to the work areas (e.g., wet/slippery floors, weather
conditions)
B. Unsafe Acts
1. Causes related to material handling/repetitive motion activities (e.g., unsafe
posture, improper lifting practice)
2. Behavioral causes (e.g., failure to follow instruction, disregard of safety rules)
Model - Accident Investigation Procedure

C. Other Causes
1. Causes inherent to the task being performed (e.g., pursuit of suspect)
2. Causes inherent to the individual (e.g., pre-existing medical condition)
Underlyinq Causes
Unsafe acts and conditions listed above are often the results of deficiencies in the
management system; and these management deficiencies are the underlying causes of
accidents. Here are some examples of underlying causes:
A. Unsafe Acts
1. Employee unaware of the hazards
Underlying cause: Lack of training
2. Employee unable to perform in a safe and healthy manner
Underlying cause: Personal protective equipment was not provided
B. Unsafe Conditions
1. Management was not aware of the hazard
Underlying causes: a. Periodic safety inspections were not conducted
b. The hazard was not identified during inspections
2. The hazard was not corrected
Underlying cause: Delay in correction even though the hazard was known
Chanqe Analysis
There are different techniques to determine the cause(s) of an accident. One of the
techniques is change analysis, which compares between:
. the manner a task was performed at the time of accident; and
. the manner the task should have been performed in order to prevent the
accident.
This is a 6-step process:
Step 1:
Step 2:
Step 3:
Step 4:
Step 5:
Step 6:
Define the 'accident situation (i.e., What happened in the accident?). The
information gathered from injured employee, witnesses, physical
evidence, and existing records should enable you Jo define what
happened in the accident (e.g., an employee slipped on a spill.).
Define what should have happened in an accident-free situation (e.g., spill
was reported to housekeeping, spil was cleaned up immediately, and
employee paid attention to where he/she was going). .
Compare the Step 1 and Step 2.
Identify and describe the differences between Step 1 and Step 2.
Analyze each difference individually for its effect on the accident. This
would identify what was, and what was not, affected by the differences.
List the possible causes and then determine the most likely causes.
Model - Accident Investigation Procedure

The following is a flow chart of the analysis:
1. Accident
Situation
l
I 3. Compare I
l
2. Comparable
Accident-free
Situation
II. Corrective Actions
.
4. Identify
the Differences
5. Analyze
Differences
for Effect on
Accident
6. Determine
the Causes
There are immediate, temporary, and/or permanent corrective actions that should be
taken by department supervisors. An example of an immediate action is evacuating all
employees from a dangerous area. An example of a temporary action is putting up
warning tape around an accident area, and a permanent action is repairing a piece of
equipment.
To determine the appropriate corrective actions, staff must consider the causes of the
accident, including the underlying causes. Additionally, the following factors have to be
considered:
. Feasibilty
. Cost
. Impact on productivity
. Amount of supervision required
A feasible corrective action must be accepted by the management, supervisors, and
employees.
To correct unsafe acts of employee(s), conduct appropriate employee training and
observe employee actions. Other actions may include personal counseling. To correct
unsafe conditions, the following three types of corrective actions are listed in the order
of preference: .
1. Engineering Control - e.g., repair the broken chair, pot holes, etc.
2. Administrative Control- e.g., move employees to another location
3. Personal Protective Equipment - e.g., provide respirator, safety glasses, etc.
Model - Accident Investigation Procedure

IV. Documentation
To assist your investigation, three different accident investigation forms are attached:
1. For general use
2. For repetitive motion injuries
3. For material handling (e.g., lifting and pushing) injuries
Upon the completion of the form, please forward a copy to your department Return-to-
Work Coordinator (for employee accidents) and to your Risk Management Coordinator
(for other accidents/losses).
You may want to keep your interview notes, photographs, and other records for followup
and future reference.
Photoqraphs
Photographs provide documentation about what had happened, especially
photographs were taken right after the accident. Photographs should include:
. An overview of the accident site
. A close-up view of the accident site
. Equipment involved in the accident
. Provide adequate depth and height perception
if the
Each photograph should be identified with the date and time the photo was taken and
what it depicts. For digital photography, it is a good practice to keep good notes in the
field. A hard copy of the digital photos should then be printed out as soon as possible.
Caution: Accident reports, including interview notes and photographs, could become
admissible evidence in a legal proceeding.
V. Implement Corrective Actions
After the corrective actions are recommended, ensure those actions are being properly
implemented. The submission of a work order for repair does not mean the repair was
conducted. It is prudent to inspect the place or equipment to ensure proper repair.
Also, if training is part of the corrective actions, it is important to observe employees
actions/behavior after training.
What should you do if fraud is suspected?
If fraud is suspected, contact the Fraud Hotline at 1-800-544-6861 or Mr. Alex Rossi
(arossi(gcao.co.la.ca.us) of the Chief Administrative Offce Risk Management Branch at
213-738-2154.
Model - Accident Investigation Procedure

APPENDIX I: REPETITIVE MOTION INJURIES
Repetitive motion injuries (RMI), a.k.a. cumulative trauma disorders, are injuries
resulting from stress or strain imposed on some part of the body from overuse and a
task's repetitive nature. Carpal Tunnel Syndrome is an example of RMI.
The tasks that may cause RMI include typing, computer mouse use and recurring
motions such as twisting, turning, and grasping. Injured employees are not limited to
office workers.
RMI can also be caused by outside activities such as sports, hobbies, and a second job.
I. Gatherinq Information
For this type of injury, it is very important to interview the injured employee and his/her
supervisor. You may want to ask the following questions: .
1. What specific tasks does the employee perform that result in injury?
2. How many hours per day/week does the employee perform these tasks?
3. Does the employee only perform these tasks during certain parts of the year?
4. How many months/years has the employee performed these tasks?
5. Does the employee have outside activities that may contribute to the injury?
6. Was an ergonomic evaluation conducted for the employee prior to the accident?
7. Was the employee trained on ergonomics?
8. Is proper ergonomic equipment in place?
II. Determine the Causes
RMI can usually be attributed to one or more of the following causes:
1. Lack of proper ergonomics equipment/furniture
2. Unsafe posture (e.g., employee fails to maintain neutral wrist
typing)
3. Lack of a departmental ergonomic program (underlying cause)
4. Lack of ergonomic training (underlying cause)
posture while
III. Corrective Actions
Examples of the corrective actions for RMI are:
1. Perform ergonomic evaluations of the employee workstations and work practices;
if assistance is needed, contact the Chief Administrative Office Loss Control and
Prevention Section at 213-351-5479
2. Train employees on ergonomics; training and other resource materials are
available from the Chief Administrative Office Loss Control and Prevention
Section
Model - Accident Investigation Procedure

APPENDIX II. MATERIAL HANDLING INJURIES
Material handling injuries are injuries resulting from handling objects and persons. It is
usually caused by a single event, like lifting a patient or a heavy load. However, the
injury can also be a result of the cumulative effect of bending and twisting in handling
objects and persons. A common material handling injury is back injury.
If the injury is a result of cumulative effect, the procedures for investigating Repetitive
Motion Injuries as stated in Appendix I can also be used.
i. Gatherinq Information
Gather information about the object/person that the employee was handling in the
accident. You may want to ask the following questions:
1. What is the weight of the person/object?
2. What is the size and shape of the object?
3. How many employees were handling this person/object at the time?
4. Was the employee using any equipment to aid his/her handling of the
person/object?
5. Was the employee trained on proper body mechanics/lifting techniques?
6. What distance was the object carried?
One may estimate the weight of an object by using the following:
1. A gallon of water is 8.3 pounds
2. A SOD-sheet ream of paper is 5 pounds
Ii. Determininq the Causes
Big, heavy, and odd shaped objects are difficult to handle. If the handling of such
objects was involved in the accident, the employee might need to use carts, dolles,
hand trucks, or other material handling equipments. If the lifting of a person was
involved, the use of lifting equipment might be needed.
Material handling injury can usually be attributed to one or more of the following causes:
1. Improper handling/lifting techniques
2. Failure to follow instruction
3. Unavailability of material handling equipment (underlying cause)
4. Lack of training (underlying cause)
III. Corrective Actions
Examples of the corrective actions for material handling injury are:
1. Train employees in proper body mechanics/lifting techniques, including proper
use of equipment
2. Ensure the availability of material handling equipment
Model - Accident Investigation Procedure

Supervisor's Investigation Report
of
Job Related Ilness or Injury
Date of Injury: Time: Location of Accident: Department:
AM PM
Employee's Name: Work Shift: Job Title: Supervisor:
1. How it happened? Go to scene and reconstruct accident. Ask what was done and how it
was done. Witnesses?
2. What caused the accident? List all facts and study situation at time of accident. Was it
procedure, material, equipment, environment, or other cause?
3. How can similar accidents be prevented? Training, new equipment, change of procedure,
change of attitude, etc.
4. What have you done to prevent similar future accidents?
5. When did your department have its last safety meeting?
Date Number of employees attending
I nvestigated by: Date:
Telephone Number: Email:
Model - Accident Investigation Procedure

MATERIAL HANDLING INJURY ACCIDENT INVESTIGATION REPORT
Employee Name (as it appears on payroll) / Department, Branch, Section
How did the pain from this injury develop? D Suddenly D Gradually
I Date of Accident
If GRADUALLY, did the employee report or complain of any physical problems or symptoms prior to the accident? DYes D No
If YES, when and to whom?
MATERIAL HANDLING INJURY
Description of object / person being handled / lifted at time of injury
Approximate size: Approximate weight:
Please describe handling / lifting techniques used. Did the injury involve?
Bending D Yes D No
Carrying D Yes D No
Lifting D Yes D No
Pushing D Yes D No
Pulling D Yes D No
Reaching D Yes D No
Twisting D Yes D No
With what frequency, pace and duration is the object / person handled / lifted? (e.g., 10 times / hour for 3 hours)
Did environmental factors (heat, cold, vibration, weather) contribute to this accident? DYes D No If YES, in what way?
What material handling equipment and / or safety devices were available to the employee?
If applicable, was this equipment being properly used? DYes D No DNA If NO, please explain.
Has the employee received training in proper body mechanics / lifting techniques? DYes D No
If YES, please indicate approximate date and type of training given.
Investigator's Signature Date
Title
Model - Accident Investigation Procedure
I Email:
Phone #
( )

REPETITIVE MOTION INJURY ACCIDENT INVESTIGATION REPORT
Employee Name (as it appears on payroll) / Department, Branch, Section Date of Accident
How did the pain from this injury develop? 0 Suddenly 0 Gradually
If GRADUALLY, did the employee report or complain of any physical problems or symptoms prior to the accident? 0 Yes 0 No
If YES, when and to whom?
REPETITIVE MOTION INJURY
What specific activities does the employee perform with his / her wrists, hands, arms, shoulders, and/or neck?
How many hours per day? How many hours per week?
Are there any seasonal variations in the employee's work schedule? 0 Yes 0 No If YES, please explain.
How long has the employee worked in this position?
If the employee has outside employment concurrently, what type of position is it?
If the employee works in an office, has an ergonomics evaluation been conducted on employee's workstation?
If YES, please indicate approximate date of evaluation and recommendations given.
0 Yes 0 No 0 Don't Know
Has the employee received training in office ergonomics/proper body mechanics/lifting techniques? 0 Yes 0 No
If YES, please indicate approximate date and type of training given.
Investigator's Signature Date
Title
Email:
Model - Accident Investigation Procedure
Phone #
( )

FAMILY AND MEDICAL LEAVE OVERVIEW
The family and medical leave laws provide certain employees with up to 12 workweeks
of unpaid, job-protected leave a year, and requires group health benefits to be
maintained during the leave as if employees continued to work instead of taking leave.
Purpose of Familv and Medical Leave Laws
. Allows employees to balance their work and family life by taking reasonable unpaid
leave for certain family and medical reasons.
. Accommodates the legitimate interests of employers, and minimizes the potential for
employment discrimination on the basis of gender, while promoting equal
employment opportunity for men and women.
Leave Laws
. Federal Family and Medical Leave Act (FMLA).
. Caliornia Family Rights Act (CFRA)
. Pregnancy disabilty leave under the California Fair Employment Housing Act.
Emplover CoveraQe
. All public agencies
. Private sector employers who employ 50 or more part-time or full-time employees.
Employee EIiQibilty for FMLA & CFRA
. Completed at least 12 months (52 weeks) of County service, which need not be
consecutive. If an employee is maintained on the payroll for any part of a week,
including any period of paid (e.g., sick leave, vacation, non-elective leave, etc.) or
unpaid leave (e.g., Workers' Compensation, STD, L TD, etc.), the week is counted as
a week of employment.
. Worked at least 1250 hours during the 12-month period prior to the start of the
leave. Definition of "hours worked" is same as under the FLSA, i.e., actual hours of
vacation, holiday, sick leave, etc.
. Includes temporary, part-time, contract employees.

Employee Eliaibilty for Preanancy Disabilty Leave
. Upon first day of employment.
Leave Entitlement Under the FMLA and CFRA
A covered employer must grant an eligible employee up to a total of 12 workweeks of
unpaid leave in a 12-month period for one or more of the following reasons:
. For the birth of son or daughter, and to care for the newborn child.
. For the placement with the employee of a child for adoption or foster care, and to
care for the newly placed child.
. To care for an immediate family member (spouse, child, or parent - but not a parent
"in-law") with a serious health condition.
. When the employee is unable to work because of a serious health condition.
. Treatment for substance abuse.
Leave to care for a newborn child or for a newly placed child must conclude within
12 months after the birth or placement.
Spouses employed by the County are limited to a combined total of 12 workweeks of
family leave for the following reasons:
. Birth and care of a child;
. For the placement of a child for adoption or foster care, and to care for the newly
placed child; and
. To care for an employee's parent who has a serious health condition.
Leave Entitlement for Preanancy Disabilty Leave
. Disabilty due to pregnancy, childbirth or related medical condition.
prenatal care and severe morning sickness.
Includes
. Up to four months per pregnancy. For a full-time employee who works five eighthour
days per week, "four months" means 88 working days of leave entitlement,
based on an average of 22 working days per month for four months. ,

. For employees who work more or less than five days a week, or who work on
alternative work schedules, the number of working days that constitutes "four
months" is calculated on a pro rata or proportional basis.
Serious Health Condition
"Serious health condition" means an illness, injury, impairment, or physical or mental
condition that involves:
. Any period of incapacity or treatment connected with inpatient care (i.e., an
overnight stay) in a hospital, hospice, or residential medical care facility; or
. A period of incapacity requiring absence of more than three calendar days from
work, school, or other regular daily activities that also involves continuing treatment
by (or under the supervision of) a health care provider; or
. Any period of incapacity due to pregnancy, or for prenatal care; or
(Note: An employee's own incapacity due to pregnancy is covered as a
serious health condition under the FMLA but not under CFRA.)
. Any period of incapacity (or treatment therefrom) due to a chronic serious health
condition (e.g., asthma, diabetes, epilepsy, etc.); or
. A period of incapacity that is permanent or long-term due to a condition for which
treatment may not be effective (e.g., Alzheimer's, stroke, terminal diseases, etc.); or
. Any absences to receive multiple treatment (including any period of recovery
therefrom) by, or on referral by, a health care provider for a condition that likely
would result in incapacity of more than three consecutive days if left untreated (e.g.,
chemotherapy, physical therapy, dialysis, etc.). .
Health Care Provider
A health care provider is a:
. Doctor of Medicine or Osteopathy authorized to practice medicine or surgery by the
State in which the doctor practices;
. Podiatrist;
. Dentist;
. Clinical Psychologist;
. Optometrist;

. Chiropractor (limited to treatment consisting of manual manipulation of the spine to
correct a subluxation as demonstrated by X-ray to exist);
. Nurse Practitioner and Nurse-Midwife;
. Clinical Social Worker;
. Health care provider recognized under the County sponsored or County approved
union sponsored health plans;
. Christian Science Practitioner listed with the First Church of Christ, Scientist in
Boston, Massachusetts;
. A health care provider who practices in another country, who is authorized to
practice in that country and who is practicing within the law as defined by that
country.
Intermittent or Reduced Schedule Leave
. Intermittent or reduced schedule leave may be taken when medically necessary to
care for a seriously ill family member, or because of the employee's serious health
condition.
. Intermittent or reduced schedule leave may be taken to care for a newborn or newly
placed adopted or foster care child. CFRA allows the employee to take intermittent
leave for a minimum two-week duration without management agreement. CFRA
also requires management to grant intermittent leave for less than two weeks
duration on any two occasions.
. If leave is foreseeable, employees must make a reasonable effort to schedule their
intermittent leave so as to not unduly disrupt the work of the department. Likewise,
management must make a reasonable effort to meet the employee's needs.
. Only the amount of leave actually taken while on intermittent or reduced schedule
leave may be charged as family/medical leave.
. Employees may not be required to take more leave than is needed. For example,
management cannot insist that the intermittent leave be taken in increments of more
than one hour. However, when the intermittent leave taken is for less than a onehour
period, management can apply the department's standard payroll policy.

AssiQnment to an Alternate Position
. Management may assign an employee who needs intermittent leave or a reduced
schedule to an available alternate position for which the employee is qualified and
which better accommodates the recurrent periods of leave.
. Assignment to an alternate position must comply with Civil Service Rules, existing
MOUs, and the ADA.
. An "alternate position" for this purpose means another position which has equivalent
pay and benefits, but not necessarily equivalent duties. An existing job may be
altered to better accommodate the need for leave provided the modification is in
compliance with other state or federal laws, County ordinance, and/or labor
agreements.
. Management may transfer an employee to a part-time position so long as the
employee receives the same hourly equivalent in terms of pay and benefits. Cannot
change item sub.
. When the employee no longer needs family/medical leave, the employee must be
returned to his/her same position or an equivalent full-time position.
Paid Versus Unpaid Leave
. FMLA/CFRA/Pregnancy Disability Leave are unpaid leaves.
. Employees may use accrued time to cover leave.
. Employees are not permitted to use one day per month of accrued time to receive
their County contribution, unless only one day is all the employee has.
. Cannot force an employee to use accrued time to cover leave.
Leave InteQration
. FMLA and CFRA run concurrently except:
-- During a pregnancy disability leave (FMLA applies but CFRA does not).
-- Following a pregnancy disability leave, when FMLA is exhausted but CFRA is not.
. Workers' Compensation leave may run concurrently with FMLA and CFRA:
-- Except during Labor Code 4850 leave, which applies to safety members only.

Continuation of Health Benefits
. Cafeteria plan contributions and other benefits continue if employee uses paid leave.
. County must continue medical and dental coverage while employee is on unpaid
family/medical leave. Twelve-week cap on eligibility period.
. Employee on unpaid leave must continue to make payments toward medical and
dental premiums to same extent as while working. Employee may continue other
benefits, e.g., life insurance, health and dependent spending account, STD, L TD on
a "non-deduct" basis.
Medical Certification
. Employer may require certification if need for leave is based on serious health
condition of employee or employee's immediate family member.
. Must allow at least 15 calendar days to submit and notify employee in writing.
. If substantial reason to doubt initial medical cert, may request second and third
opinions. List of qualified medical examiners obtained through Occupational Health
Programs:
-- Department must pay for offce visit and reimburse employee for any reasonable
"out-of pocket," travel expenses.
-- Third opinion is final and binding.
. CFRA prohibits the asking of a diagnosis in regard to the serious health condition of
an employee or family member.
. If employee fails to provide medical certification, not family/medical leave.
Recertification
. If leave is for pregnancy, chronic or long-term illness, may request no more often
than 30 days, unless circumstances change significantly or employer receives
information casting doubt upon stated reasons for absence.
. If the minimum duration of the employee's incapacity is more than 30 days,
employer may not request recertification until the minimum duration is passed,
unless employee requests extension of leave, circumstances change or employer
receives information casting doubt on employee's reason for leave.

Desianation
. Employer is required to designate family/medical leave.
. Employee does not have to mention family/medical leave - need only to advise of a
qualifying reason.
. Employee does not have the option to defer designation of leave.
. Employer must designate leave within two business days of knowledge that leave is
for qualifying reason.
. Designation may be oral but must be confirmed in writing no later than the following
payday, unless payday is less than one week after oral notice then must be no later
than the subsequent payday.
. No retroactive designation if employer had knowledge.
. Retroactive designation permissible if employer learns that leave was for a qualifying
reason after the leave begins.
. No designation after employee's return to work except:
-- Employer learns employee off for qualifying reason after return to work and
designates within two business days, or
-- If employer was not aware employee off for qualifying reason and employee
wishes leave counted as family/medical leave. Employee must notify employer
within two business days of return to work that leave was for qualifying reason.
. Preliminary designation is okay if employer knows employee off for qualifying reason
but has not been able to confirm, e.g., waiting for medical certification.
Failure to Desianate
. Time does not count against 12-week entitlement.
. Employee still entitled to protection of family/medical leave regulations, e.g.,
absences may not be counted against employee for disciplinary purposes.
Notice
. Management can require employee to provide 30 days advance notice if not an
emergency and need for leave is foreseeable. Otherwise, notice is based on what is
practical given the facts and circumstances:
-- Cannot enforce this requirement if Department of Labor notice not posted.

Postina Reauirement
. FMLA and CFRA notices must be posted in prominent place, readily seen by
employee and job applicants.
Common Mistakes
. Failure to notify employee of family/medical
leave rights:
-- In additional to posting required notices, employers are required to distribute a
written policy and provide notice to employees when they are taking
family/medical leave.
. Expecting employee to request family/medical leave. THE BURDEN IS ON THE
EMPLOYER TO DESIGNATE.
. Failure to notify employee that leave is being counted toward 12-week entitlement.
. Taking disciplinary action against an employee for using FMLA leave.
. Failure to grant family/medical leave to care for or comfort a seriously ill parent or
child.
. Failure to reinstate an employee to the same or an equivalent position and working
conditions upon return from family/medical leave.
. Failure to grant leave due to misunderstanding of what constitutes a serious health
condition.
. Failure to request certification and not giving the employee written notice of at least
16 calendar days to obtain it.
Failure to Complv With Reaulations
. Complaints to Department of Labor and/or Department of Fair Employment and
Housing.
. Civil suits against employer and/or individuals, e.g., supervisor or manager.

FMLA Record-Keepina Reauirements
Required records include:
. Basic payroll information on employee.
. Dates of designated leave.
. Increments of time in which leave was taken.
. Copies of any notices the employee furnished to the employer.
. Information on employer-provided benefits.
. Records of any employer-employee disputes regarding the designation of leave as
family/medical leave.

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SAMPLE 2
YR 1 YR2
Months 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9
FMLA
PDLL
CFRA
Year 1: Employee is disabled by pregnancy for 4 months, then requests maximum leave to care for
new baby.
Year 2: In year 2, employee requests maximum leave to care for ill spouse (1250 hour eligibility met).
FMLA/CFRA run concurrently.

SAMPLE 3
YR 1
Months Dec Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov
FMLA
PDLL
wc
Employee is disabled due to a work related injury for 8 months. Workers Comp, FMLA and CFRA run
concurrently for first 3 months, or the 12 week entitlement. Workers' Compensation continues after
FMLA and CFRA have been exhausted.

SAMPLE 4
YR 1
Months Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec Jan
FMLA 32 32 32 32 32
CFRA 32 32 32 32 32
Employee is disabled due to his own serious health condition; returns to work in April on a reduced
schedule - 4 days/week. Receives cancer treatment 1 day/week.
Employee goes on intermittent FMLA/CFRA leave beginning in April and uses 32 hours/month. In
August, employee exhausts all FMLA/CFRA leave for the year, or the 12 workweek entitlement.

FMLA requires covered employers to provide up to 12
weeks of unpaid, job-protected leave to "eligible"
employees for certn family and medical reasons.
Employees are eligible if they have worked for their
employer for at least one year, and for 1,250 hours over
Reasons for Taking Leave:
Unpaid leave must be granted for any of the following
reasons:
. to care for the employee's child after bir, or placement
for adoption or foster care;
. to care for the employee's spouse, son or daughter, or
parent who has a serious health condition; or
. for a serious health condition that makes the employee
unable to perfonn the employee's job.
At the employee's or employer's option, certain kinds of
paid leave may be substituted for unpaid leave.
Advance Notice and Medical
Certification:
The employee may be required to provide advance leave
notice and medical certification. Takig of leave may be
denied if requirements are not met.
. The employee ordinarly must provide 30 days advance
notice when the leave is "foreseeable."
. An employer may requie medical certification to
support a request for leave because of a serious health
condition, and may require second or thrd opinions (at
the employer's expense) and a fitness for duty report to
return to work.
Job Benefits and Protection:
. For the duration ofFMLA leave, the employer must
maintain the employee's health coverage under any
"group health plan."
Æ U.s. Department of Labor
~~ Employment Standards Administration
Wage and Hour Division
Washington, D.C. 20210
the previous 12 months, and if there are at least 50
employees with 75 miles. The FMLA pennits
employees to tae leave on an intennttent basis or to
work a reduced schedule under certain circumstaces.
. Upon retu from FMLA leave, most employees must
be restored to their original or equivalent positions with
equivalent pay, benefits, and other employment tenns.
. The use ofFMLA leave cannot result in the loss of any
employment benefit that accrued prior to the star of an
employee's leave.
Unlawful Acts by Employers:
FMLA makes it unlawfl for any employer to:
. interfere with, restrain, or deny the exercise of any
right provided under FMLA:
. discharge or discriminate against any person for
opposing any practice made unawfl by FMLA or for
involvement in any proceedig under or relating
to FMLA.
Enforcement:
. The U.S. Deparent of Labor is authorized to
investigate and resolve complaints of violations.
. An eligible employee may brig a civil action against
an employer for violations.
FMLA does not affect any Federal or State law
prohibiting discrimination, or supersede any State or
local law or collective bargaining agreement which
provides greater family or medicalleav~. rights.
For Additional Information:
If you have access to the Internet visit our FMLA
website: http://www.doL.gov/esa/whd/fmla.To
locate your nearest Wage-Hour Office, telephone our
Wage-Hour toll-free infonnation and help line at 1-866-
4USW AGE (1-866-487-9243): a customer service
representative is available to assist you with referral
infonnation from 8am to 5pm in your time zone; or log
onto our Home Page at http://www.wagehour.doI.gov.
WH Publication 1420
Revised August 2001
'u.s. GOVERNMENT PRINTING OFFICE 2001-476-344/49051
,.

STATE OF CALIFORNIA - State and Consumer Services Agency
DEPARTMENT OF FAIR EMPLOYMENT & HOUSING
2014 T Street, Suite 210
Sacramento, CA 95814-5212
"NOTICE B"
FAMILY CARE AND MEDICAL LEAVE (CFRA LEAVE)
AND PREGNANCY DISABILITY LEAVE
Arnold Schwarzenegger, Governor
. Under the California Family Rights Act of 1993 (CFRA), if you have more than 12 months of
service with us and have worked at least 1,250 hours in the 12-month period before the
date you want to begin your leave, you may have a right to an unpaid family care or
medical leave (CFRA leave). This leave may be up to 12 workweeks in a 12-month period
for the birth, adoption, or foster care placement of your child or for your own serious health
condition or that of your child, parent or spouse.
. Even if you are not eligible for CFRA leave, if disabled by pregnancy, childbirth or related
medical conditions, you are entitled to take a pregnancy disability leave of up to four
months, depending on your period(s) of actual disability. If you are CFRA-eligible, you
have certain rights to take BOTH a pregnancy disability leave and a CFRA leave for reason
of the birth of your child. Both leaves contain a guarantee of reinstatement to the same or
to a comparable position at the end of the leave, subject to any defense allowed under the
law.
. If possible, you must provide at least 30 days advance notice for foreseeable events (such
as the expected birth of a child or a planned medical treatment for yourself or of a family.
member). For events which are unforeseeable, we need you to notify us, at least verbally,
as soon as you learn of the need for the leave.
. Failure to comply with these notice rules is grounds for, and may result in, deferral of the
requested leave until you comply with this notice policy.
. We may require certification from your health care provider before allowing you a leave for
pregnancy or your own serious health condition or certification from the health care
provider of your child, parent, or spouse who has a serious health condition before allowing
you a leave to take care of that family member. When medically necessary, leave may be
taken on an intermittent or a reduced work schedule.
. If you are taking a leave for the birth, adoption or foster care placement of a child, the basic
minimum duration of the leave is two weeks and you must conclude the leave within one
year of the birth or placement for adoption or foster care.
. Taking a family care or pregnancy disability leave may impact certain of your benefits and
your seniority date. If you want more information regarding your eligibility for a leave and/or
the impact of the leave on your seniority and benefits, please contact
r 1.
Employer's Telephone Number
DFEH-100-21 (01/00)

STATE OF CALIFORNIA - State and Consumer Services Agency Arnold Schwarzenegger, Governor
DEPARTMENT OF FAIR EMPLOYMENT & HOUSING
2014 T Street, Suite 210
Sacramento, CA 95814-5212
"NOTICE A"
PREGNANCY DISABILITY LEAVE
Under the California Fair Employment and Housing Act (FEHA), if you are disabled by
pregnancy, childbirth or related medical conditions, you are eligible to take a pregnancy
disability leave (POL). If you are affected by pregnancy or a related medical condition, you are
also eligible to transfer to a less strenuous or hazardous position or to less strenuous or
hazardous duties, if this transfer is medically advisable. You are also eligible to receive
reasonable accommodation for conditions related to pregnancy, childbirth, or related medical
conditions if you request it with the advice of your health care provider.
. The POL is for any period(s) of actual disability caused by your pregnancy, childbirth or
related medical conditions up to four months (or 88 work days for a full time employee) per
pregnancy.
. The POL does not need to be taken in one continuous period of time but can be taken on an
as-needed basis.
. Time off needed for prenatal care, severe morning sickness, doctor-ordered bed rest,
childbirth, and recovery from childbirth would all be covered by your POL.
.
.
Generally, we are required to treat your pregnancy disability the same as we treat other
disabilities of similarly situated employees. This affects whether your leave will be paid or
unpaid.
You may be required to obtain a certification from your health care provider of your
pregnancy disability or the medical advisability for a transfer or reasonable accommodation.
The certification should include:
1 ) the date on which you become disabled due to pregnancy or the date of the medical
advisability for the transfer or reasonable accommodation;
2)
the probable duration of the period(s) of disability or the period(s) for the advisability
of the transfer or reasonable accommodation; and,
3) a statement that, due to the disability, you are unable to work at all or to perform any
one or more of the essential functions of your position without undue risk to yourself,
the successful completion of your pregnancy or to other persons or a statement that,
due to your pregnancy, the transfer or reasonable accommodation is medically
advisable.
. At your option, you can use any accrued vacation or other accrued time off as part of your
pregnancy disability leave before taking the remainder of your leave as an unpaid leave.
We may require that you use up any available sick leave during your leave. You may also
be eligible for state disability insurance for the unpaid portion of your leave.
.
Taking a pregnancy disability leave may impact certain of your benefits and your seniority
date. If you want more information regarding your eligibility for a leave, the impact of the
leave on your seniority and benefis, and our policy for other disabilities, please contact -
Contact Person
DFEH-100-20 (01/00)
at Employer's
Employer's Telephone Number

Family and Medical Leave
Frequently Asked Questions
1. Q. How much leave am i entitled to under FMLA?
A. If you are an "eligible" employee, you are entitled to 12 weeks of leave for certain family and
medical reasons during a 12-month period.
2. Q. Do the 1,250 hours include paid leave time or other absences from work?
A. No. The 1,250 hours include only those hours actually worked for the employer. Paid leave and
unpaid leave, including MLA leave, are not included.
3. Q. Does workers' compensation leave count against an employee's FMLA leave
entitlement?
A. It can. FMLA leave and workers' compensation leave can run together, provided the reason for
the absence is due to a qualifying serious illness or injury and the employer properly notifies the
employee in writing that the leave wil be counted as FMLA leave.
4. Q. Can the employer count leave taken due to pregnancy complications against the 12
weeks of FMLA for the birth and care of my child?
A. Yes. An eligible employee is entitled to a total of 12 weeks of FMLA leave in a 12-month period.
If the employee has to use some of that leave for another reason, including a difficult pregnancy,
it may be counted as part of the 12-week FMLA leave entitlement.
5. Q. Can the employer count time on maternity leave or pregnancy disability as FMLA leave?
A. Yes. Pregnancy disability leave or maternity leave for the birth of a child would be considered
qualifying FMLA leave for a serious health condition and may be counted in the 12 weeks of
leave so long as the employer properly notifies the employee in writing of the designation.
6. Q. Do the 12 months of service with the employer have to be continuous or consecutive?
A. No. The 12 months do not have to be continuous or consecutive; all time worked for the
employer is counted.
7. Q. Does the law guarantee paid time off?
A. No. The FMLA only requires unpaid leave. However, the law permits an employee to elect, or
the employer to require the employee, to use accrued paid leave, such as vacation or sick leave,
for some or all of the FMLA leave period. When paid leave is substituted for unpaid FMLA leave,
it may be counted against the 12-week FMLA leave entitlement if the employee is properly
notified of the designation when the leave begins.
8. Q. Do i have to give my employer my medical records for leave due to a serious health
condition?
A. No. You do not have to provide medical records. The employer may, however, request that, for
any leave taken due to a serious health condition, you provide a medical certification confirming
that a serious health condition exists.

9. Q. Can my employer require me to return to work before I exhaust my leave?
A. Subject to certain limitations, your employer may deny the continuation of FMLA leave due to a
serious health condition if you fail to fulfill any obligations to provide supporting medical
certification. The employer may not, however, require you to return to work early by offering you
a light duty assignment.
10. Q. Can my employer make inquiries about my leave during my absence?
A. Your employer may ask you questions to confirm whether the leave needed
or being taken qualifies for FMLA purposes, and may require periodic reports on your status and
intent to return to work after leave. Also, if the employer wishes to obtain another opinion, you
may be required to obtain additional medical certification at the employer's expense, or
recertification during a period of FMLA leave. The employer may have a health care provider
representing them, contact your health care provider, with your permission, to clarify information
in the medical certification or to confirm that it was provided by the health care provider.

The Pre-Designation Form has not been
issued by the State of California. Once
the official form is issued, it will be
placed in this Reference Manual

TO:
FROM:
DATE:
W AGE STATEMENT - MONTHLY SALARIED EMPLOYEES
This employee sustained on industrial injury on
wage inormation from
Claim No:
Name:
Employee #:
BASE SALARY FLEX BONUS
MONTH/YEAR (DO NOT
DEDUCT FOR
TIME OFF)
EARNINGS
(TAXABLE
CASH)
PAY
(SPECIFY
TYPE)
Authorized Departmental Representative Phone Date
Rev. 09-15-98
. Please complete the attached
OVERTIME

DATE:
To:
From
WAGE STATEMENT - DAILY AND HOURLY EMPLOYEES
Employee:
Employee #:
Date of Injury:
The workers' compensation TPA needs the wage information for 13 months of wage
information. For example, if the date of injury is in March you would provide wage
information from March of the following year up to March of the current year.
GROSS PAY
MONTHNEAR TOTAL HOURS (INCLUDING OVERTIME
WORKED AND BONUS PAY)
Authorized Departmental Representative Phone Number Date

DATE:
TO: Name of physician
Fax number
COUNTY LETTERHEAD
WORK ABILITIES QUESTIONNAIRE
FROM: Name of RTW Coordinator
Phone number and fax number
SUBJECT: Name of employee
URGENT
Please fax response within 4 hours.
This employee has returned from a medical appointment and I am attempting to
determine if there is an appropriate transitional assignment for the employee
considering his/her work abilities.
We believe that there may be work available that is of a comparable level of activity to
the employee's activities of daily living. Please complete the section below so we may
better understand the employee's physical capabilties.
ACTIVITIES OF DAILY LIVING: check each item that the employee is able to perform
o Light housekeeping (tidying, wiping kitchen counters, etc.)
o Washing dishes
o Vacuuming/sweeping
o Driving personal vehicle
o Hobbies/sports (exercise, golf, etc.)
o Child care - age of children
o Personal grooming (bathing, dressing, etc.)
o Outdoor gardening/watering with hose
o Taking walks
o Other

(Your Dept. Name Here)
COUNTY OF LOS ANGELES
WORK HARDENING TRANSITIONAL ASSIGNMENT AGREEMENT
Employee: Title:
Employee No. :
Claim#:
Date of Injury:
Pay Location #
Today's Date:
Facilty: Dept. # :
Dr. has released me to return to work with the following
recovery limitations/work restrictions:
In an effort to assist you in returning to full duty, we have identified a temporary work hardening
assignment that is compatible with your limitations (duties listed on back of this form). Your
placement on this temporary assignment is intended to prevent further injury or aggravation to
your present condition. You must agree that you wil work within your treating physician's
recovery limitations/work restrictions. Also, if given any duties outside these limitations, you will
immediately notify your supervisor in writing. If you refuse this temporary work hardening
transitional assignment, you may lose your entitlement to Workers' Compensation disability
benefits.
The total length of your Work Hardening Transitional Assignment should last no longer than 12
weeks beginning with the date listed below. If, at the conclusion of your Work Hardening
Assignment, it has been medically determined that you are unable to return to your usual and
customary job, an interactive process will be conducted with you to determine a possible future
assignment.
Total Length of Work Hardening Transitional Assignment: to
Start Date End Date
(If the End Date changes in the future, prepare and fax the "Amended" WHT AA
form to appropriate CAO staff.)
NOTE TO SUPERVISOR: Please review with the injured worker their recovery limitations and
Work Hardening Transitional Assignment before signing. Complete and return signed original
to the Return-To-Work office and fax to ( )
Employee Signature
Supervisor Signature
(Side I)
Print Name Date
Print Name Date

(Your Dept. Name Here)
COUNTY OF LOS ANGELES
WORK HARDENING TRANSITIONAL ASSIGNMENT AGREEMENT
The duties for the temporary work hardening transitional assignment referenced on Side 1 of this
form are as follows:
(Side 2)
Csr:g:ERTWW orkhardeningAssignmentAgreement.word

SECTIONæ:~REE
-' _. - .
- _.-
..~;~y/lev~,nd,ll
..
-.~

Name:
Employee #:
Department #:
Job Classification:
JOB DESCRIPTION
JOB SUMMARY/DESCRIPTION OF TASKS
TOOLS, EQUIPMENT AND MACHINERY
PHYSICAL DEMANDS - List duration, frequency, and tasks performed
. Sitting
. Walking (distance)
. Standing
. Bending
. Squatting
. Climbing (height)
. Kneeling

. Crawling
. Twisting
. Lifting + Carrying (weight, objects)
. Hand Use (right or left hand dominant)
./ Simple Grasping
./ Power Grasping
STRESS FACTORS
./ Fine Manipulation
./ Pushing and Pullng
./ Reaching (above or below shoulders)
. Amount of work performed (caseload, production standards, overtime)
. Interpersonal Contacts (clients, superiors, subordinates, co-workers, public)
. Other?
Supervisor Signature Date
Employee Signature Date

BECTIQ

Reassign to:
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
ALTERNATE OPTIONS TO ACCOMMODATE WORK RESTRICTIONS/
POSSIBLE TEMPORARY ASSIGNMENTS
Security Guard
Greeter (Open doors and directs people information).
For Fire/Police and other departments, consider presentations in the community to
schools, Boy/Girl Scouts, and other groups in the community about services and safety.
Public/Safety information.
Inspections of vehicles for safety (ambulance, County vehicles).
Parking lot monitor.
Update bulletin boards with employee benefits or replace old information on racks with
current updated information, update directories.
Light maintenance.
Update County phone directory.
Vehicle maintenance - clean, fill with gas, take for serviæ on County vehicles.
Special projects.
Receptionist
Lunchroom - straighten; wipe down tables, sort magazines.
Help coworkers reorganize, re-file, create new fie folders.
Alphabetize paperwork, fies or information for special projects.
Open mail and distribute.
Put postage on outgoing mail/light clericaL.
Shred confidential information or old documents.
Check offce for any equipment needing maintenance, supplies ordering.
In Animal Shelter - take the animals for a walk, community presentation.
Complete job descriptions.
Verify employee's addresses and phone numbers, time keeping assistance.
Collection information from supervisors for available job tasks to be assigned to injured
workers on work hardening.
Assist development of desktop offæ manuals.

MODIFIED OPTIONS FOR SPECIFIC BODY
PARTS AN POSSIBLE WORK
RESTRICTIONS
Purpose: To assist in determining temporary or permanent placement during restrictive periods of
work. For more suggestions visit the Job Accommodation Network on line at www.jan.
Back - Liftin!!. bendin!!, stoopin!!, positions for prolon!!ed periods
. Someone lifting boxes, suggest moving items individually.
. Use carts, hand trucks, or coworkers for assistance.
.
.
.
Remove lifting requirements from the job.
Change workstation, chair or stool to prevent bending.
Allow employee to alternate positions with breaks for 5 to 10 seconds every 5 to 10
minutes.
Correct ergonomics for workstation, footrest, adjust chair, raise computer.
Arm - No use. no repetitive use, no liftin!!. reachin!!, pushin!! or pulln!!
. Use other arm.
Reposition workstation, if in office; use Dictaphone with non-injured arm instead of typing.
.
.
.
.
Use headset instead of phone receiver.
Redistribute heavy portion of job to coworkers.
Limit pushing and pulling to non-injured arm.
Hand-Repetitive movements. !!rrppin!!. !!raspin!!. writn!!. liftin!!/carrvin!!. fine
manipulation, use of hand pushin!! and pulln!!
. Type instead of writing.
Write or dictate instead of typing.
.
.
.
.
Use non-injured hand.
Frequent breaks for brief periods.
Reassign job duties to coworkers.
Reposition workstation.
Use mechanical devices to move items.
Provide an automatic vehicle if using a vehicle with a manual transmission.
Reassign driving duties.
Knees - Stand/walk. liftcarrv. kneelinii/sQuat. climbinii
. Provide a chair.
.
.
Reassign duties for coworker.
Provide mats for standing.
Allow frequent short breaks and allow to alternate positions.
Reduce lift/carry job duties.
Assign alternate position.

County of Los Angeles
Return to Work Program
TRG
STANING: This means standing stationar, without tag steps. Be sure to descrbe suraces in
detaiL. For example; wet/dr, concrete, asphalt, caret, mud, softard soil, gravel pitched or
sloped surace/ten-ain, etc. Descrbe durations at each OCCUIence, frequency with walkig,
squattng, etc.
WALKIG: This means the motion of taking steps. It may be one or two steps or varng
distances. Be sure to describe the average to maximum distance at each occun-ence.
Describe the surfaces walked over (as previously described in STANDING). Is it intermttent
with standing, etc.? Does it occur up ramps, slopes, etc.?
SITTING: Be sure to descrbe the frequency and durations that this occurs at each OCCUIence. A
detailed descrption of what the employee is sittg on is required. Is the seat adjustable in height?
Is the back adjustable in support? Does the seat and/or back have benefit of padding? Does the
chair/stool have ar? Is the chair/stool set on wheels/castors? For vehicle seats, are they
specialized hydraulic or air-shock seats, etc.? If the employee is sittng on the ground or on
strctual members, what is the constrction?
~

KNELING: Describe frequency and durations at each OCCUIence and whether it occurs on one or
both knees. Describe the surfaces that kneeling occurs on.
SQUATTING: Ths means fully bent or nearly fully bent at the knees, supporting the weight ofthe
body on the heels/toes, with the hidquarers close to the ground. Be sure to describe why the
employee is squatting, i.e.: to access/view low levels of work; as the proper method oflifting, etc.
Describe frequency and durations at each occun-ence and on what surface.
CRAWLING: Describe the body supported on the hands and knees. Describe frequency and
durations at each occun-ence and over what surfaces. Is it occurng in small or confined spaces
(dimensions if possible), over/under/or through what (equipment, strctues, attics, crawl spaces,
etc.)?
di
CLIMBING: This describes the motion of climbing ONLY. Not balancing. It includes, but is not
necessarily limited to: stairs (describe number and height of each); steps (describe number and
height, i.e.: in and out of vehicles); ladders - attached and portable (describe height and
construction); structural members (describe construction and type). State whether climbing is
perfonned in conjunction with carng or balancing.
The aforementioned physical demands represent the Primar Demands. This meaning that none
of them can be pedormed in conjunction with each other. By breakig down these demands first,
into frequency, you can derive your total hours of a given work shift, based on the length of that
shift The physical demands that follow may be able to be performed in conjunction with each
other or those previously mentioned.

REACHING: Be sure to describe whether it is with major or minor Land or bilaterally. Whether
it requires a full extension or less-than-full extension of the arm(s), what level (measurement),
durations at each occun-ence, frequency and whether it is repetitive in nature. Is it performed in
conjunction with pushing, pulling, lifting, jerking, tossing/throwing, etc.?
PUSHING: Means exerting force on an object, to move the object away from the force. Describe if
this is performed by the hands (major, minor or bilateral), feet/legs, shoulder, back, etc. Is it in the
manner of supporting weight, manipulating levers or controls, pedals, etc.? Does it require a full or
less-than-full extension of the arm(s)? At what level and in what manner, i.e.: sliding; slapping;
shoving; kicking; etc.? If rolling/wheeled devices, describe the number of wheels, weights of the
object, condition of the wheels and over what surfaces it is pushed. EXAMPLE: "The employee is
pushing and pulling in a sweeping manner, on an industrial type pushbroom, at waist level, requiring
a bilateral grasp. Arms are used to a full and less-than-full extension, for brief but repeated
durations.
PULLING: Means "exerting force on an object, to move it closer to the source of the force." This
includes jerking, dragging, tugging, etc. It may be in a "manhandling" manner, or on drawer, carts,
controls, materials, etc. Describe if performed with the major or minor hand or bilaterally, at what
level, frequency and durations at each occurrence. Is it repetitive in nature? Is it performed in
conjunction with simple or firm grasping, turning, twisting or bending of the wrst(s)? Does it
require a full or less-than-full extension of the arm(s)? Describe, what is being pulled, i.e., a rolling
device, materials, etc., and describe the weight. EXAMPLE: "The employee pulls on a rope, 20
feet in length, attached to a bucket weighing within 30 pounds, to lift the bucket from inside a tank.
This requires bilateral use of the hands, in conjunction with a firm grasp, at waist level, pulling in a
hand-over-hand manner. Arms are used to a full and less-than-full extension, for brief but repeated
durations of up to two minutes at each occun-ence. This task is performed from two to i 0 times per
day."

TWISTING: Body pars that need to be addressed are as follows. No other body pars need to be
addressed in ths category, but these must be:
1.) Wrists/Forears - Describe the frequency and durations at each OCCUIence, whether it is
in conjunction with a fi or simple grasp, whether it is repetitive in natue or in conjunction with
the use of tools/equipment which subject the hands/ar to vibrations. (Note the severty of
vibrations.) The descrption of twisting is not that of bending or tug of the wrsts. You will
tyicaUy see it in the use of certain tools and equipment, i.e.: screwdrvers, wrenches, manipulation
of knobs, valves, etc.
2.) Waist - Twistig ofthe waist is described as two body pars. It is broken down by mid or
upper waist. The direction of twsting must be addressed, i.e.: front to left or vice versa; front to
right or vice versa; left to right or right to left. If possible, descrbe to what degree the employee is
twisting, i.e.: 10 degrees, 60 degrees, etc. Note whether it is repetitive in natue, frequency and
durations at each OCCUIence. Is it pedormed in conjunction with liftng, stooping, single or
bilateral reachig, pushing or pulling?
3.) Neck - Describe the frequency and durations at each OCCUITence and if the motion is done
to aid visually while completing other tasks. Indicate the direction of the motion and the degree
that the neck moves. Example: The motion is from center to right, back to center, or from center
to the left, back to center, up to a 45-degree angle at each OCCUITence.

BENDING: The body pars needing to be addressed in this category are as follows:
1.) Waist - Bending of waist will most often be in a forward direction. State the direction and the
degree that the waist bends. Example: The motion is in a forward direction up to a 90-degree angle
on each OCCUIence.
2.) Neck - Describe the frequency and durations at each OCCUIence and if the motion is done to
aid visually while completing other tasks. Indicate the direction of the motion and the degree that
the neck moves. Example: The motion is from center, moving the chin in a downward motion,
back to center, or from center, moving the chin in an upward motion, up to a 35-degrec angle on
each OCCUIence.

LIFTTNG: Descrbe frequency and durations at each OCCUIence. Break down and state the
most frequently lifted weights first Is it major, minor or bilateral handed lifting, its weight (or
weight range) and vertical distance lifted to or from its stationar position. Does it require a fi or
simple grasp and how is it lifted (handle, cord, etc.)? State its size and whether it is awkward to
handle. Is the employee liftg full or paral weight? Is the liftg assisted by use ofleverage, ore
or more workers, etc. (each worker supportg an equal amount of weight)? Is the liftg repetitive
in natue? Is it peeormed in conjunction with twstig and/or stooping?
~
CARYING: Separate from lifting. These are two different demands. CaITying is the motion of
moving an object from one point to another by taking steps (not pushing or pulling). Describe the
frequency and durations at each OCCUIence, over what surfaces, weights and whether it requires a
single or bilateral grasp or is caIed on another part ofthe body, i.e.: around the waist; on the
shoulder, back, head, etc. Is it caIed with or without assistance, and for what distance?

GRIPPING/GRASPING: Describe whether it is power or simple grasping. Power grasping is
the type required
.
to manpulate most hand tools,
.
or when applying force or pressure, i.e.: lifting
heavy objects; use of a screwdriver, wrench, hammer, shovel, etc. Simple grasping is the type
required to handle something, although not necessarly while exerting force, i.e.: holding a
telephone receiver, paperwork; wrting instrments; etc. State whether the grasp/grp is performed
with the major, minor, left or right hand, or bilaterally (in tandem). Is it performed in conjunction
with turg and bending ofthe wrsts, or in conjunction with the use oftools subjecting the
hands/ars to vibrations (note severity)? Describe the frequency and durations at each OCCUIence
and whether it is repetitive in natue.
FINGER MANIPULATIONilEXTERITY: This includes pinching, picking, fingering or any
other tasks performed by the fingers, not the hands. Is it major, minor or bilateral? Is a sense of
touch in the fingers required? Is the work intricate? Describe the frequency and durations at each
OCCUITence.

PHYSICIAN OFFICE CONTACT AND SUGGESTIONS FOR WORKING WITH STAFF
Purpose: Provide Return to Work Coordinators (RTWC) with a set of guidelines to
follow when making personal contacts, so as to ensure positive and more productive
ways of securing information, assistance, and cooperation in obtaining clarification.
When it becomes necessary to discuss the employee's ability to perform their usual and
customary assignment or obtain clarification of restrictions, do the following:
. Pull the file and review the work restrictions and history of extensions.
. Have the job description handy.
. Make phone contact: tell the medical offcer your name, title, and department
name, and ask to speak to the doctor, nurse or disability manager regarding the
employee's restrictions or clarification of restrictions.
. Fax a job description to discuss with them, if necessary.
. If you are informed that they wil not be able to assist you at the present time,
ask when a returned call wil be made. Call back if it is more than a few hours
or a day has passed since the provided date.
. Place in writing your request for clarification and fax to the physician with the job
description and a copy of the work restrictions issued, if you're not getting timely
responses.
. Inform the staff at the physician's office that the employee-patient signed a
release* to enable the their office to talk about return to work and restrictions. If
they state that a release is necessary, fax it to them.
. Do not ask for a diagnosis.
. Document your efforts.

If the physician's office is uncooperative, ask them about the advisability of a signed
permission statement from the employee. Again if the physician will not talk with you
without the permission of the employee/patient, indicate that you understand the
situation and that you will secure the permission required.
In your closing remarks, be certain to give the physician's office your name and
telephone number. Remind them that you are the contact person to assist the
employee in return to work matters.
If the physician's office staff remain uncooperative, the RTWC should ask for assistance
from:
. The Claims Adjustor at the workers' compensation TPA.
. Occupational health Service for a non-occupational ilness/injury.
If the physician informs the RTWC that the patient has had complications and needs:
. Additional tests, to make a determination.
. Other medical opinions and/or consultations.
The RTWC should ask what duties the employee/patient can perform while waiting for
the tests and consultations.
SUGGESTIONS FOR WORKING WITH IN-HOUSE STAFF:
RTWC:
. Do not become personally involved if the employee does not want to cooperate
or refuses an assignment, do not take it as a personal rebuff.
. Do not become personally involved if the supervisor does not want to take the
employee back to work with work restrictions.
. Be completely objective; do not be judgmental in your comments and actions.
SUPERVISOR:
. The employee may not return to work to do all the job activities and will need the
supervisor's support. This is not pampering, but does place the supervisor in a
New role - one of helper to his/her staff.
. The ability to place an employee shows good supervisory skills.
. Return of an employee to work removes the negative effect of the employee's
absence, and begins to restore an even workload.
. It is better to have segments of a job being done rather than not to have the job
done.

Doctor
My name is
patient:
Angeles.
SAMPLE CONVERSATION
and I am the RTWC/Supervisor of your
of the department name of the the County of Los
I am in receipt of restrictions you have issued on Mr/Ms
and require clarification to ensure that I am observing the
restrictions correctly, as I do not want to aggravate the employee's
injury/illness.
Our employee, your patient Jemplovee's name) helps this Department
fulfil its mission for the taxpayers of this County through (briefly
describe Department's mission). To meet these obligations of public
service, we need each of our employees at work as much as possible
and perform to the best of their ability and without undue physical
hardship.
We have no wish to intrude in the professional relationship you have
with our employee, nor are we attempting to have our employee perform
all the significant functions of their assignment, until you believe it is
medically feasible and safe to do so.
Your assistance in obtaining clarification is appreciated. We will make
every effort to meet those restrictions, which you require for our
employee.
We would like to send you a job description, so you may know what
work your patient does, and the conditions under which the work is
done; we believe this will be of value to you to clarify the restrictions
your issued or determine if the employee can return to full duty.
In particular, we have questions regarding the following restrictions
Mention to physician that having clarification of the restrictions and the
times they will be in effect will aid in placing the employee in a suitable
job.
L.
2.
3.
4.
5.
RESTRICTIONS LENGTH OF TIME

SECTIQ

Date
Employee Name
Street
City, State Zip
Dear Employee:
DEPARTMENT LETTERHEAD
RE: MODIFIED WORK OFFER
Attached is a conditional offer of modified work for your review. This job offer ìs based
upon the most current information available to us. You have 30 days to respond to this
offer. If you do not respond or accept, the offer wil be rescinded.
Should your physician provide additional recommendations after you have returned to
work, a meeting wil be scheduled with you to discuss the impact of these new
recommendations.
Be advised that the job duties may change when we receive more concrete information
from your physician. We are committed to working with you to maintain an active work
status as your work restrictions change.
If you have any further questions or concerns, please contact me at
Sincerely,
Department RTWC
Attachments

Rehabiltation Unit
California Division of Workers' Compensation
Form RU-94
NOTICE OF OFFER OF MODIFIED OR ALTERNATIVE WORK
Purpose:
To document an offer of modified or alternative work by the employer at the time of
injury. The form also documents the acceptance or rejection of modified or alternate
work by the injured employee. The RU-94 is to be used only for injuries which occur on
or after 1-1-94.
Submitted by:
The claims administrator obtains the response of the injured worker and submits the
form to the Rehabilitation Unit.
When prepared:
The form is prepared at the time of the offer of modified or alternative work by the
employer or claims administrator. This form is not to be used to document a plan for
modified or alternate work offered subsequent to advising the worker that modified or
alternative work was not available.
Where submitted:
Initially to the injured worker within 30 days of the acceptance or rejection of the offer,
then it is submitted to the Rehabilitation Unit, together with a RU-105.
Form completion:
The employer or claims administrator completes the information in the top box. The
employee completes the section so marked.
Accompanvin~ document:
The RU-94 is submitted with a RU-105 Notice of Termination. The submitted RU-94
must also include a list of duties required of the position and wages offered.
Rehabilitation Unit action:
The Rehabilitation Unit wil not take action unless the employee objects by filing a RU-
103, Request for Dispute Resolution, to the Notice of Termination.
Note: -If the offer is not accepted or rejected within 30 days of the offer, the offer
is deemed to be rejected by the employee. The employer has the option to file a
RU-105, Notice of Termination, or extend the 30-day period by mutual agreement.

NOTICE OF OFFER OF MODIFIED OR ALTERNATIVE WORK
THIS SECTION COMPLETED BY EMPLOYER OR CLAIMS ADMINISTRATOR:
Employer (name of firm)
(name of job)
Attach a list of the duties required of the position.
You may contact concerning this offer.
Date of offer: Date job starts:
is offering you the position of a
Phone No.:
Claims Administrator: Claim Number:
NOTICE TO EMPLOYEE Name of employee:
Date offer received:
You have 30 calendar days from receipt to accept or reject this offer of modified or alternative work. If you reject this job
offer, you will not be entitled to rehabiltation services unless:
Modified Work
A. The proposed modification(s) to accommodate required work restrictions are inadequate.
B. The modified job wil not last 12 months.
Alternative Work
A. You cannot perform the essential functions of the job; or
B. The job is not a regular position lasting at least 12 months; or
C. Wages and compensation offered were less than 85% paid at the time of injury; or
D. The job is beyond a reasonable commuting distance from residence at time of injury.
THIS SECTION TO BE COMPLETED BY EMPLOYEE
- 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 vocational rehabilitation services.
Signature
I feel I cannot accept this offer because:
NOTICE TO THE PARTIES
If the offer is not accepted or rejected within 30 days of the offer, the offer is deemed to be rejected by the employee.
The employer or claims administrator must forward a completed copy of this agreement to the Rehabilitation Unit with a Notice of
Termination (DWC Form RU-105) within 30 days of acceptance or rejection.
If a dispute occurs regarding the above offer or agreement, either party may request the Rehabilitation Unit to resolve the dispute by
fiing a Request for Dispute Resolution (DWC Form RU-103) at the applicable Rehabilitation Unit. The Rehabilitation Unit venue is
the same as the Workers' Compensation Appeals Board. If no WCAB case exists, file with a Rehabiltation Unit at the appropriate
district office.
Date
MANDATORY FORMAT
STATE OF CALIFORNIA
DWC-RU-94 (01/03) §10133.12

DWC-AD 10133.53 NOTICE OF OFFER OF MODIFIED OR ALTERNATIVE WORK
For injuries occurring on or after 1/1/04
THIS SECTION COMPLETED BY CLAIMS ADMINISTRATOR:
Employer (name of firm)
(name of job)
You may contact
Date of offer:
Date job starts:
is offering you the position of a
concerning this offer. Phone No.:
Claims Administrator: Claim Number:
NOTICE TO EMPLOYEE Name of employee:
Date of Injury: Date offer received:
You have 30 calendar days from receipt to accept or reject the attached offer of modified or alternative work.
Regardless of whether you accept or reject this offer, the remainder of your permanent disability payments may
be decreased by 15%. However, if you fail to respond in 30 days or reject this job offer, you wil not be entitled
to the supplemental job displacement benefit unless:
Modified Work 0 or Alternative Work 0
A. You cannot perform the essential functions of the job; or
B. The job is not a regular position lasting at least 12 months; or
C. Wages and compensation offered are less than 85% paid at the time of injury; or
D. The job is beyond a reasonable commuting distance from residence at time of injury.
THIS SECTION TO BE COMPLETED BY EMPLOYEE
- 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 entiled to the Supplemental
Job Displacement Benefit.
Signature
I feel I cannot accept this offer because:
NOTICE TO THE PARTIES
If the offer is not accepted or rejected within 30 days of the offer, the offer is deemed to be rejected by the employee.
The employer or claims administrator must forward a completed copy of this agreement to the Administrative Director within 30 days
of acceptance or rejection. (A.D., "SJDB," Division of Workers' Compensation, P.O. Box 420603, SF, CA 94102-3660)
If a dispute occurs regarding the above offer or agreement, either party may request the Administrative Director to resolve the dispute
by filing a Request for Dispute Resolution (Form DWC-AD 10133.55) with the Administrative Director.
Date
MANDATORY FORM (Page 1 of 2)
STATE OF CALIFORNIA
(08/05)

DWC-AD 10133.53 NOTICE OF OFFER OF MODIFIED OR ALTERNATIVE WORK
For injuries occurring on or after 1/1/04
POSITION REQUIREMENTS
Actual job title:
Wages: $ per
- -
Hour Week Month
Is salary of modified/alternative work the same as pre-injury job? Yes No
- -
Is salary of modified/alternative work at least 85% of pre-injury Yes No
job?
Wil job last at least 12 months? Yes.- -
-
No
-
Is the job a regular position required by the employer's business? Yes No
Work
location:
Name of doctor who approved job restrictions (optional):
report::
Date of last a ment of Tem ora Total Disabilit :
Pre arer's Name:
Preparer's Si nature: Date
Date of
MANDATORY FORM (Page 2 of 2)
STATE OF CALIFORNIA
(08/05)

- DWC-AD 10133.55 Has
- -
employer accepted this claim? DWC Use Only
Yes No
Request for Dispute Resolution Has liability
- -
for injury been -found by the WCAB?
Before the Administrative Yes No
Has it been more than 60 days since TTD ended?
Director
Yes No
(For injuries occurring on or after Has PPD award been stipulated, issued/approved?
1/1/04) -Yes -No
_Original _Response
Social Security Number
I WCAB Number I DWC Unit Number
Employee Name (Last) (First) (MI) Phone Date of Birth
Address (Street) (City) (State) (Zip)
Employer Name Phone Insurance Company Name; Or, if Self-Insured, Certificate Name
Address Adjusting Agency Name (if adjusted)
City, State, Zip Claims Mailng Address
Date of Injury
City, State, Zip Phone No.
I Claim Number
Employee Representative (if any) Employer Representative
Firm Name Firm Name
Address Address
City, State, Zip Phone No. City, State, Zip Phone No.
Vocational & Return to Work Counselor (if applicable)
Firm Name Representative Name
Address (Street, City, State, Zip Phone No.
The Administrative Director is requested to resolve the following dispute because the parties disagree on: (Please describe and attach all pertinent
documents)
Summary of Parties' Informal Efforts to Resolve this Dispute Proof of Service: I declare under penalty of perjury under the laws of the
State of California that on the date written below, I mailed a copy of this
request with a copy of any documents included with this request to the
following parties at the following addresses:
Administrative Director, (SJDB), Division of Workers' Compensation,
P.O. Box 420603, San Francisco, CA 94102-3660
Name of Requester Date Signature Date
(Mandatory Form DWC-AD 10133.55 08/05)

DWC-AD 10003 NOTICE OF OFFER OF REGULAR WORK
For injuries occurring on or after 1/1/05
THIS SECTION TO BE COMPLETED BY EMPLOYER OR CLAIMS ADMINISTRATOR:
Claims Administrator: Claim Number:
(Name of Insurer/Claims Administrator)
Based on the opinion of _treating physician _QME - AME , you are able to return to the
position you held at the time of your injury.
(Name of Physician)
Date you are eligible to return to job: (as stated in the above physician's report)
Employer:
Job Title:
Location of Job:
Starting Date:
Start and End time of Shift:
(Name of Firm)
You may contact concerning this position. Phone No.:
(Name of Contact Person)
This position will last for at least 12 months.
You will be paid Wages and compensation of $
compensation paid to you at the time of your injury.
, which is equivalent to the wages and
If the location of the job offered is different than the location of the job you held at the time of your injury, or if you are
being offered a different shift than the shift you held at the time of your injury, the job location must be within a
reasonable commuting distance from your residence at the time of your injury, unless you agree to waive this condition.
You will be deemed to have waived this condition if you accept the above offer of work and do not object to the location
within twenty days of receipt of this notice.
MANDATORY FORMAT
STATE OF CALIFORNIA
Proposed March 3, 2005

THIS SECTION TO BE COMPLETED BY EMPLOYEE:
Name of employee: Date offer received:
- I accept this offer of regular work. (You must report to work on the date the job starts or the date you and your
employer agree to.)
- I agree to waive the condition that the offered job be within a reasonable commuting distance of my residence at the time of my
injury.
- I reject this offer of work.
I am rejecting this offer because:
I understand that whether I accept or reject this offer, my remaining permanent disability payments may be increased by
15%.
Signature
Date:

DEPARTMENT LETTERHEAD
Date
Employee Name
Employee Address
Sample
Order to Return to Usual and Customary Work Letter
Dear Employee:
The Department has received notification from the
insert TPA name that temporary work restrictions have been imposed. We
believe they are compatible with your usual and customary work assignment. You are
hereby notified that you are ordered to return to work on insert date . You
are to report to: insert name, location and time
Your failure to comply with this order may result in disciplinary action up to and including
discharge from County service.
Should you have any questions regarding your disability status, please contact
at
Sincerely,
DEPARTMENT HEAD

§10133.50 Definitions
Article 7.5
Supplemental Job Displacement Benefit
(a) The following definitions apply for iniures occunng on or after Januar 1. 2004:
(1) Alternative Work. Work that the employee has the ability to perfonn. that offers
wages and compensation that are at least 85 percent of those paid to the employee at the
time of iniur. and that is located within reasonable commuting distance of the
employee's residence at the time ofiniur.
(2) Approved Training Facility. A training or skills enhancement facility or institution
that meets the requirements of section 10133.58.
(3) Claims Administrator. The person or entity responsible for the payment of
compensation for a self-administered insurer providing security for the payment of
compensation required by Divisions 4 and 4.5 of the Labor Code. a self-administered
self-insured employer. or a third-party claims administrator for a self-insured employer.
insurer. legally unnsured employer. or ioint powers authority.
(4) Employer. The person or entity that employed the iniured employee at the time of
IDlur.
(5) Essential Functions. Job duties considered crucial to the employment position held or
desired by the employee. Functions may be considered essential because the position
exists to perfonn the fuction. the fuction requires specialized expertise. serious results
may occur if the fuction is not perfonned. other employees are not available to perfonn
the fuction or the fuction occurs at peak periods and the employer canot reorganze
the work flow.
(6) Insurer. Has the same meanng as in Labor Code section 3211.
(7) Modified Work. Regular work modified so that the employee has the ability to
perfonn all the fuctions of the iob and that offers wages and compensation that are at
least 85 percent of those paid to the employee at the time of iniur. and located within a
reasonable commuting distance ofthe employee's residence at the time ofiniur.
(8) Nontransferable Training Voucher. A document provided to an employee that allows
the employee to emoll in education-related training or skills enhancement. The
document shall include identifying infonnation for the employee and claims
administrator. specific infonnation regarding the value of the voucher pursuant to Labor
Code section 4658.5.
(9) Notice. A required letter or fonn generated by the claims administrator and directed to
the iniured employee.
Final Regulations (June 2, 2005) Supplemental Job Displacement Benefit Regulations
Title 8, California Code of Regulations, sections 10133.50 - 10133.60

(10) Offer of Modified or Alternative Work. An offer to the injured employee of
medically appropriate employment with the date-of-injur employer in a fonn and
maner prescribed by the Administrative Director.
(11) Paries. The employee. the claims administrator and their designated representatives.
if any.
(12) Pennanent Parial Disability Award. A final award of pennanent parial disability
detennined by a Workers' Compensation Adminstrative Law Judge or the Workers'
Compensation Appeals Board.
(13) Regular Work. The employee's usual occupation or the position in which the
employee was engaged at the time of iniur and that offers wages and compensation
equivalent to those paid to the employee at the time of injur. and located within a
reasonable commuting distance of the employee's residence at the time ofiniur.
(14) Supplemental Job Displacement Benefit. An educational retraining or skills
enhancement allowance for iniured employees whose employers are unable to provide
work consistent with the requirements of Labor Code section 4658.6.
(15) Vocational & Retur to Work Counselor (VTWC). A person or entity capable of
assisting a person with a disability with development of a retu to work strategy and
whose regular duties involve the evaluation. counseling and placement of disabled
persons. A VRTWC must have at least an undergraduate degree in any field and three or
more years full time experience in conducting vocational evaluations. counseling and
placement of disabled adults.
(16) Work Restrctions. Pennanent medical limitations on employment activity
established by the treating physician. Qualified Medical Examiner or Agreed Medical
Examiner.
"
Authority: Sections 133.4658.5.5307.3. Labor Code.
Reference: Sections 124.4658.1.4658.5. and 4658.6. Labor Code.
Final Regulations (June 2, 2005) Supplemental Job Displacement Benefit Regulations
Title 8, California Code of Regulations, sections 10133.50 - 10133.60

§10133.51 Notice of Potential Ri2ht to Supplemental Job Displacement Benefit
(a) This section and section 10133.52 shall only apply to iniures occurrng on or after
Januar 1. 2004.
the last pavment oftemporary disability. ifnot previously
(b) Within 10 days of
provided. the claims administrator shall send the employee. by certified mail. the
mandatory form "Notice of Potential Right to Supp1emental Job Displacement
Benefit Form" that is set forth in Section 10133.52.
Authority: Sections 133.4658.5. and 5307.3. Labor Code.
Reference: Section 4658.5. Labor Code.
Final Regulations (June 2,2005) Supplemental Job Displacement Benefit Regulations
Title 8, California Code of Regulations, sections 10133.50 - 10133.60

Notice of Potential Ri2ht to Supplemental Job Displacement Benefit Form
(Mandatory Form)
If your iniury causes permanent partial disability. which prevented you from returng to
work within 60 days of the last payment of temporar disability. and the claims
administrator has not provided you with a Form DWC-AD 10133.53 "Notice of Offer of
Modified or Alternative Work." you may be eligible for a supplemental iob dis?lacement
benefit in the form of a nontransferable voucher for education-related retraining or skill
enhancement, or both. at state approved or accredited schools.
The amount of the voucher for the supplemental iob displacement benefit wil be as
follows:
Up to four thousand dollars ($4.000) for a permanent parial disability award of less than
15%.
Up to six thousand dollars ($6.000) for a permanent parial disability award between 15
and 25 %.
Up to eight thousand dollars ($8.000) for a permanent parial disability award between 26
and 49 %.
Up to ten thousand dollars ($1O.000) for a permanent parial disability award between 50
and 99 %.
A permanent parial disability award is issued by a Workers' Compensation
Administrative Law Judge or the Workers' Compensation Appeals Board. You may also
settle your potential eligibility for a voucher as par of a compromise and release
settlement for a lump sum payment. Any settlement must be reviewed and approved by a
Workers' Compensation Administrative Law Judge.
The voucher may be used for payment of tuition. fees. books. and other expenses
required by the school for retraining or skill enhancement. Not more than 10 percent of
the voucher moneys may be used for vocational or return to work counseling. A list of
vocational retu to work counselors is available on the Division of Workers'
Compensation's website ww.dir.ca.gov or upon request.
If you are eligible. and you have not already sett1ed the benefit. you wil receive the
voucher from the claims administrator within 25 calendar days from the date the
permanent partial disability award is issued by the Workers' Compensation
Administrative Law Judge or the Workers' Compensation Appeals Board.
If modified or alternative work is available. you wil receive a Form DWC-AD 10133.53
"Notice of Offer of Modified or Alternative Work" from the claims administrator within
30 days of the termination of temporar disability indemnity payments. The claims
Final Regulations (June 2, 2005) Supplemental Job Displacement Benefit Regulations
Title 8, California Code of Regulations, sections 10133.50 - 10133.60

administrator will not be required to pay for supplemental iob displacement benefits if the
offer for modified or alternative work meets the following conditions:
(1) You have the ability to perfonn the essential functions ofthe iob provided~
(2) the iob provided is in a regular position lasting at least 12 months~
(3) the iob provided offers wages and compensation that are at least 85
percent of those paid to you at the time of the iniur~ and
(4) the iob is located within reasonable commuting distance of
at the time of iniur.
your residence
If there is a dispute regarding the Supplemental Job Displacement Benefit. the employee
or claims administrator may file Fonn DWC-AD 10133.55 "Request for Dispute
Resolution before the Administrative Director."
If you have a question or need more infonnation, you can contact your employer or the
claims administrator listed below. You can also contact a State Division of Workers'
Compensation Infonnation and Assistance Offcer.
Date:
Name of Claims Administrator:
Address of Claims Administrator:
Email (optional):
Phone No.:
Final Regulations (June 2, 2005) Supplemental Job Displacement Benefit Regulations
Title 8, California Code of Regulations, sections 10133.50 - 10133.60

§10133.54 Dispute Resolution
(a) This section and section 10133.55 shall only apply to iniures occurrng on or after
Januar 1, 2004.
(b) When there is a dispute regarding the Supplemental Job Displacement Benefit. the
employee. or claims administrator may request the Administrative Director to reso1ve the
dispute.
(c) The pary requesting the Administrative Director to reso1ve the dispute shall:
(1) Comp1ete Fonn DWC-AD 10133.55 "ReQuest for Dispute Reso1ution before the
Administrative Director:"
(2) Clearly state the issue(s) and identify supporting infonnation for each issue and
position:
(3) Attach all pertinent documents:
(4) Submit the original request and all attached documents to the Administrative Director
and serve a copy of the request and all attached documents on all paries: and
(5) Sign and date the proof of service section ofFonn DWC-AD 10133.55 "Request for
Dispute Resolution before the Administrative Director."
(d) The opposing party shall have twenty (20) ca1endar days from the date of the proof of
service of the Request to submit the original response and all attached documents to the
Administrative Director and serve a coPY ofthe response and all attached documents on
all paries.
( e) The Administrative Director or his or her designee may request additiona1 infonnation
from the paries.
(t) The Administrative Director or his or her designee shall issue a written detennination
and order based sole1y on the request. response. and any attached documents within thirty
(30) ca1endar days of the date the opposing pary'S response and supporting infonnation
is due. If the Administrative Director or his or her designee reQuests additional
infonnation. the written detennination shall be issued within thirty (30) calendar days
from the receipt of the additional infonnation. In the event no decision is issued within
sixty (60) calendar days of the date the opposing pary'S response is due or within sixty
(60) calendar days ofthe Administrative Director's receipt of the reQuested additional
infonnation. whichever is later. the reQuest shall be deemed to be denied.
(g) Either party may appeal the detennination and order ofthe Administrative Director by
filing a written petition together with a Declaration of Readiness to Proceed pursuant to
section 10414 with the local distrct office of the Workers' Compensation Appeals Board
within twenty calendar days of the issuance of the decision or within twenty days after a
request is deemed denied pursuant to subdivision (t). The petition shall set forth the
Final Regulations (June 2,2005) Supplemental Job Displacement Benefit Regulations
Title 8, California Code of Regulations, sections 10133.50 - 10133.60

specific factual and/or legal reason(s) for the appeal. A coPy ofthe petition and a copy of
the Declaration of Readiness to Proceed shall be concurrently served on the
Administrative Director.
Authority: Sections 133.4658.5. and 5307.3. Labor Code.
Reference: Sections 4658.5 and 4658.6. Labor Code.
Final Regulations (June 2,2005) Supplemental Job Displacement Benefit Regulations
Title 8, California Code of Regulations, sections 10133.50 - 10133.60

DWC-AD 10133.55 Has
-
employer accepted this claim? DWC Use Only
Yes No
Request for Dispute Resolution Has liability
- -
for injury been -found by the WCAB?
Before the Administrative Yes No
Has it been more than 60 days since TTD ended?
Director
Yes No
(For injuries occurring on or after Has PPD award been stipulated, issued/approved?
1/1/04) -Yes -No
_Original _Response
Social Security Number
I WCAB Number I DWC Unit Number
Employee Name (Last) (First) (MI) Phone Date of Birth
Address (Street) (City) (State) (Zip)
Employer Name Phone Insurance Company Name; Or, if Self.lnsured, Certificate Name
Address Adjusting Agency Name (if adjusted)
Cit, State, Zip Claims Mailng Address
Date of Injury
City, State, Zip Phone No.
I Claim Number
Employee Representative (if any) Employer Representative
Firm Name Firm Name
Address Address
City, State, Zip Phone No. City, State, Zip Phone No.
Vocational & Return to Work Counselor (if applicable)
Firm Name Representative Name
Address (Street, City, State, Zip Phone No.
The Administrative Director is requested to resolve the following dispute because the parties disagree on: (Please describe and attch all pertinent
documents)
Summary of Parties' Informal Efforts to Resolve this Dispute Proof of Service: I declare under penalty of perjury under the laws of the
State of California that on the date written below, I mailed a copy of this
request with a copy of any documents included with this request to the
following parties at the following addresses:
Administrative Director, (SJDB), Division of Workers' Compensation,
P.O. Box 420603, San Francisco, CA 94102.3660
Name of Requester Date Signature Date
(Mandatory Form DWC-AD 10133.55 08/05)

§10133.56 ReQuirement to Issue Supplemental Job Displacement Nontransferable
TrainiB!!: Voucher
(a) This section and section 10133.57 shall only apply to injures occurrng on or after
Januar 1, 2004.
(b) The employee shall be eligible for the Supp1emental Job Displacement Benefit
when:
(1 ) the injur causes permanent parial disability; and
(2) within 30 days ofthe termination oftemporar disability indemnity payments, the
claims administrator does not offer modified or alternative work in accordance with
Labor Code section 4658.6; and
(3) either the injured employee does not retu to work for the employer within 60
days ofthe termination of temporar disability benefits; or
(4) in the case of a seasonal employee, where the employee is unable to retur to
work within 60 days of the termination of temporar disability benefits because the
work season has ended, the injured employee does not retu to work on the next
available work date of the next work season.
(c) When the requirements under subdivision (b) have been met, the claims
administrator shall provide a nontransferable voucher for education-related retraining
or skill enhancement or both to the employee within 25 calendar days from the
issuance of the permanent parial disability award by the Workers' Compensation
Administrative Law Judge or the Workers' Compensation Appeals Board.
(d) The voucher shall be issued to the employee allowing direct reimbursement to the
employee upon the employee's presentation to the claims administrator of
documentation and receipts or as a direct payment to the provider of the education
related training or skill enhancement and/or to the VRTWC.
(e) The voucher must indicate the appropriate level of money available to the
employee in compliance with Labor Code section 4658.5.
(f) The mandatory voucher form is set forth in Section 10133.57.
( g) The voucher shall certify that the school is approved and if outside of California,
approval is reQuired similarly to the Bureau for Private Postsecondar (BPPVE).
(h) The claims administrator shall issue the reimbursement payments to the employee
or direct payments to the VRTWC and the training providers within 45 calendar days
from receipt of the completed voucher, receipts and documentation.
Authority: Sections 133, 4658.5, 4658.6, and 5307.3, Labor Code.
Reference: Sections 4658.5 and 4658.6, Labor Code.
Final Regulations (June 2,2005) Supplemental Job Displacement Benefit Regulations
Title 8, California Code of Regulations, sections 10133.50 - 10133.60

Supplemental Job Displacement
Nontransferable Traininf! Voucher Form
(Form DWC-AD 10133.57 - Mandatory Form)
For iniures occurrng on or after 1/1/04
You have been determined eligible for this nontransferable. Supplemental Job
Displacement Voucher. This voucher may be used for the payment of tuition. fees.
books. and other expenses required by a state approved or accredited school that YOU
enroll in for the purose of education related retraining or skill enhancement. or both.
The state approved or accredited school wil be reimbursed upon receipt of a documented
invoice for tuition. fees. books and other required expenses required by the school for
retraining or skil enhancement. If YOU pay for the eligible expenses. YOU may be
reimbursed for these expenses upon submission of documented receipts. No more than 10
percent of the value of this voucher may be used for vocational or retu to work
counseling. If YOU decide to voluntarly withdraw ITom a program. YOU may not be
entitled to a full refud of the voucher amount utilized.
Please present this original letter to the state approved or accredited school and/or the
Vocational & Return to Work Counselor of your choice. chosen ITom the list developed
by the Division of Workers' Compensation's Administrative Director. in order to initiate
your training and retu to work counseling. A list of Vocational & Retu to Work
Counselors is available on the Division of Workers' Compensation's website
ww.dir.ca.gov or upon request. The school and/or counselor should contact me
regarding direct pavrent ITom your supplemental iob displacement benefit.
Iniured Employee Information: Upon completing the voucher form the iniured employee
must retur the form with receipts and documentation to the claims administrator
immediately for reimbursement. (The claims administrator must complete Nos. 1. - 8 of
this voucher form prior to sending it to the iniured employee.)
1. Iniured Employee Name
2. Address
City State Zip Code
3. Claim Number Phone Number
Claims Administrator
4. Name
5. Claims Mailing Address
Final Regulations (June 2, 2005) Supplemental Job Displacement Benefit Regulations
Title 8, California Code of Regulations, sections 10133.50 - 10133.60

6. City State Zip Code
7. Claims Representative Phone Number
8. $ is available to the iniured employee based on
Parial Disability Award
% of Permanent
The injured employee must complete Nos. 9 -19 and sien and date this voucher
form.
(VRTWC) Vocational Return to Work Counselor (if any)
9. Name Phone Number
10. Address
11. City State Zip Code
12. Funds used for vocational and retur to work counseling $
of voucher value)
(10% maximum
Trainine Provider Details (Attach additional paees for each provider if necessary.)
13. Provider Name
14. Provider Address Phone Number
15. City State Zip Code
16. Provider approval number
17. Expiration Date
18. Provider Contact Name
19. Training Cost
Injured Employee Sienature Date
Note to Claims Administrator: Upon receipt of voucher. receipts and documentation
from the employee. reimbursement payments to the employee or direct payments to
VRTWC and trainine providers must be made within 45 calendar days.
Final Regulations (June 2,2005) Supplemental Job Displacement Benefit Regulations
Title 8, California Code of Regulations, sections 10133.50 - 10133.60

§10133.58 State Approved or Accredited Schools
(a) This section shall only apply to injuries occunng on or after Januar 1, 2004.
(b) Private providers of education-related retraining or skill enhancement selected to
provide training as part of a supplemental job displacement benefit shall be:
(1 ) approved by the Bureau for Private Postsecondar and Vocational Education
(ww.bppve.ca.gov). or a Californa state agency that has an agreement with the Bureau
for the regulation and oversight of non-degree-granting private postsecondary
institutions;
(2) accredited by one of the Regional Associations of Schools and Colleges authorized by
the United States Departent of Education; or
(3) certified by the Federal Aviation Administration.
(c) Any training outside of Californa must be approved by an agency in that state sfmilar
to the Bureau for Private Postsecondar and Vocational Education.
Authority: Sections 133.4658.5. and 5307.3. Labor Code.
Reference: Section 4658.5. Labor Code.
Final Regulations (June 2,2005) Supplemental Job Displacement Benefit Regulations 19
Title 8, California Code of Regulations, sections 10133.50 - 10133.60

§10133.59 The Administrative Director's List of Vocational Return to Work
Counselors
(a) This section shall only apply to injures occurng on or after Januar 1. 2004.
Vocational & Retu to Work
Counselors (VRTWC) who perfonn the work of assisting injured employees. A
VRTWC who meets the qualifications specified in Section 10133.50(a)(15) must
apply to the Administrative Director to be included on the list throughout the year.
The list shall be reviewed and revised on a yearly basis. and shall be made
available on the website ww.dir.ca.gov or upon request.
(b) The Administrative Director shall maintain a list of
(c) The injured employee may select a Vocational & Retu to Work Counselor
whenever the assistance of a Vocational & Retu to Work Counselor is needed to
facilitate an employee's vocational training or retu to work in connection with
the Supplemental Job Displacement Benefit set forth in this Aricle.
(d) The injured employee shall be responsible for providing the VRTWC with any
necessary medical reports. However. a claims administrator shall provide a
VRTWC with any medical reports. including pennanent and stationar medical
reports. upon an employee's wrtten request and a signed release waiver.
(e) The VRTWC shall communcate with the injured employee regarding the
evaluation.
Authority cited: Sections 133.4658.5. and 5307.3. Labor Code.
Reference: Sections 4658.5.
Final Regulations (June 2, 2005) Supplemental Job Displacement Benefit Regulations 20
Title 8, California Code of Regulations, sections 10133.50 - 10133.60

§10133.60 Termination of Claims Administrator's Liabilty for the Supplemental
Job Displacement Benefit
(a) For iniures occurrng on or after Januarv 1. 2004, the claims administrator's liability
to provide a supplemental iob displacement voucher shall end if either (a)(1) or (a)(2)
occur:
(1 ) the claims administrator offers modified or alternative work to the employee, meeting
the requirements of Labor Code &4658.6, on DWC-AD Form 10133.53 "Notice of Offer
of Modified or Alternative Work";
(A) lfthe claims administrator offers modified or alternative work to the
employee for 12 months of seasonal work, the offer shall meet the following
requirements:
1. the employee was hired" on a seasonal basis prior to iniur; and
2. the offer of modified or alternative work is on a similar seasonal basis
to the employee's previous employment;
(2) the maximum funds ofthe voucher have been exhausted.
Authority: Sections 133 and 5307.3, Labor Code.
Reference: Sections 4658.1. 4658.5, 4658.6, and 5410, Labor Code; and Henrv v. WCAB
(1998) 68 Ca1.AppAth 981.
Final Regulations (June 2, 2005) Supplemental Job Displacement Benefit Regulations 21
Title 8, Californa Code of Regulations, sections 10133.50 - 10133.60

Excerpts from the Workers' Compensation Labor Code
139.5. (a) The administrative director shall establish a vocational
rehabilitation unit, which shall include appropriate professional
staff, and which shall have all of the following duties:
(1) To foster, review, and approve vocational rehabilitation plans
developed by a qualified rehabilitation representative of the
employer, insurer, state agency, or employee. Plans agreed to by the
employer and employee do not require approval by the vocational
rehabilitation unit unless the employee is unrepresented.
(2) To develop rules and regulations, to be adopted by the
administrative director, providing for a procedure in which an
employee may waive the services of a qualified rehabilitation
representative where the employee has been enrolled and made
substantial progress toward completion of a degree or certificate
from a community college, California State University, or the
University of California and desires a plan to complete the degree or
certificate. These rules and regulations shall provide that this
waiver, as well as any plan developed without the assistance of a
qualified rehabilitation representative, must be approved by the
rehabilitation unit.
(3) To develop rules and regulations, to be adopted by the
administrative director, which would expedite and facilitate the
identification, notification, and referral of industrially injured
employees to vocational rehabilitation services.
(4) To coordinate and enforce the implementation of vocational
rehabili tation plans.
(5) To develop a fee pchedule, to be adopted by the administrative
director, governing reasonable fees for vocational rehabilitation
services provided on and after January 1, 1991. The initial fee
schedule adopted under this paragraph shall be designed to reduce the
cost of vocational rehabilitation services by 10 percent from the
level of fees paid during 1989. On or before July 1, 1994, the
administrative director shall establish the maximum aggregate
permissible fees that may be charged for counseling. Those fees
shall not exceed four thousand five hundred dollars ($4,500) and
shall be included within the sixteen thousand dollar ($16,000) cap.
The fee schedule shall permit up to (A) three thousand dollars
($3,000) for vocational evaluation, evaluation of vocational
feasibility, initial interview, vocational testing, counseling and
research for plan development, and preparation of the Division of
Workers i Compensation Form 102, and (B) three thousand five hundred
dollars ($3,500) for plan monitoring, job seeking skills, and job
placement research and counseling. However, in no event shall the
aggregate of (A) and (B) exceed four thousand five hundred dollars
($4,500).
(6) To develop standards, to be adopted by the administrative
director, for governing the timeliness and the quality of vocational
rehabilitation services.
(b) The salaries of the personnel of the vocational rehabilitation
unit shall be fixed by the Department of Personnel Administration.
(c) When an employee is determined to be medically eligible and
chooses to participate in a vocational rehabilitation program, he or
she shall continue to receive temporary disability indemnity payments
only until his or her medical condition becomes permanent and
stationary and, thereafter, may receive a maintenance allowance.

Rehabilitation maintenance allowance payments shall begin after the
employee i s medical condition becomes permanent and stationary, upon a
request for vocational rehabilitation services. Thereafter, the
maintenance allowance shall be paid for a period not to exceed 52
weeks in the aggregate, except where the overall cap on vocational
rehabilitation services can be exceeded under this section or former
Section 4642 or subdivision (d) or (e) of former Section 4644.
The employee also shall receive additional living expenses
necessitated by the vocational rehabilitation services, together with
all reasonable and necessary vocational training, at the expense of
the employer, but in no event shall the expenses, counseling fees,
training, maintenance allowance, and costs associated with, or
arising out of, vocational rehabilitation services incurred after the
employee i s request for vocational rehabilitation services, except
temporary disability payments, exceed sixteen thousand dollars
($16,000). The administrative director shall adopt regulations to
ensure that the continued receipt of vocational rehabilitation
maintenance allowance benefits is dependent upon the injured worker 's
regular and consistent attendance at, and participation in, his or
her vocational rehabilitation program.
(d) The amount of the maintenance allowance due under subdivision
(c) shall be two-thirds of the employee i s average weekly earnings at
the date of injury payable as follows:
(1) The amount the employee would have received as continuing
temporary disability indemnity, but not more than two hundred
forty-six dollars ($246) a week for injuries occurring on or after
January 1, 1990.
(2) At the employee i s option, an additional amount from permanent
disability indemnity due or payable, sufficient to provide the
employee with a maintenance allowance equal to two-thirds of the
employee's average weekly earnings at the date of injury subject to
the limits specified in subdivision (a) of Section 4453 and the
requirements of Section 4661.5. In no event shall temporary
disability indemnity and maintenance allowance be payable
concurrently.
If the employer disputes the treating physician i s determination of
medical eligibility, the employee shall continue to receive that
portion of the maintenance allowance payable under paragraph (1)
pending final determination of the dispute. If the employee disputes
the treating physician i s determination of medical eligibility and
prevails, the employee shall be entitled to that portion of the
maintenance allowance payable under paragraph (1) retroactive to the
date of the employee i s request for vocational rehabilitation
services. These payments shall not be counted against the maximum
expenditures for vocational rehabilitation services provided by this
section.
(e) No provision of this section nor of any rule, regulation, or
vocational rehabilitation plan developed or adopted under this
section nor any benefit provided pursuant to this section shall apply
to an injured employee whose injury occurred prior to January 1,
1975. Nothing in this section shall affect any plan, benefit, or
program authorized by this section as added by Chapter 1513 of the
Statutes of 1965 or as amended by Chapter 83 of the Statutes of 1972.
(f) The time within which an employee may request vocational
rehabilitation services is set forth in former Section 5405.5 and
Sections 5410 and 5803.

(g) An offer of a job within state service to a state employee in
State Bargaining Unit I, 4, IS, IS, or 20 at the same or similar
salary and the same or similar geographic location is a prima facie
offer of vocational rehabilitation under this statute.
(h) It shall be unlawful for a qualified rehabilitation
representative or rehabilitation counselor to refer any employee to
any work evaluation facility or to any education or training program
if the qualified rehabilitation representative or rehabilitation
counselor, or a spouse, employer, co-employee, or any party with whom
he or she has entered into contract, express or implied, has any
proprietary interest in or contractual relationship with the work
evaluation facility or education or training program. It shall also
be unlawful for any insurer to refer any injured worker to any
rehabilitation provider or facility if the insurer has a proprietary
interest in the rehabilitation provider or facility or for any
insurer to charge against any claim for the expenses of employees of
the insurer to provide vocational rehabilitation services unless
those expenses are disclosed to the insured and agreed to in advance.
(i) Any charges by an insurer for the activities of an employee
who supervises outside vocational rehabilitation services shall not
exceed the vocational rehabilitation fee schedule, and shall not be
counted against the overall cap for vocational rehabilitation or the
limit on counselor's fees provided for in this section. These
charges shall be attributed as expenses by the insurer and not losses
for purposes of insurance rating pursuant to Article 2 (commencing
with Section 11730) of Chapter 3 of Part 3 of Division 2 of the
Insurance Code.
(j) Any costs of an employer of supervising vocational
rehabilitation services shall not be counted against the overall cap
for vocational rehabilitation or the limit on counselor i s fees
provided for in this section.
(k) This section shall apply only to injuries occurring before
January I, 2004.
(1) This section shall remain in effect only until January 1,
2009, and as of that date is repealed, unless a later enacted
statute, that is enacted before January I, 2009, deletes or extends
that date.

.
Date
Return to Work Coordinator
3333 Wilshire Blvp.
Los Angeles, CA 90010
RE: Employee
Employee # :
Claim#
Dept#/Name :
DOl
P+S Reed. :
Dear Return to Work Coordinator:
VERBAL PERMANEN'T AND STATIONARY
A verbal Permanent and Stationary (P+S) notification was received on , from ..-
Dr. . We have requested the restrictions be provided in writing as soon as_e
possible. While we are waiting for the written report, we recommend you contact the
employee to schedule an interactive meeting to discuss their knowledge and
understanding-ottheir-abmtytoretum"io-work.m- --- --- .___n___--__m ---- - . -_._..- -
Please remember that you have 30 or 60 days, depending on the date of injury, from
the date of termination of Temporary Disability (T.D.) to offer the employee a job. You
must utilze thEf RU-94 (for injuries before 1/1/04), or the DWC-AD 10133.53 (for"injuries
after 1/1/04). This job offer (even if conditional) may reduce the amount of Permanent
Disability (P.D.) the employee receives by 15%. Failure to offer a job timely may result
in the employee receiving an increase of P.D. by 15%.
Please contact me at with any questions.
Sincerely,
Claims Adjuster
-

Date
Return to Work Coordinator
3333 Wilshire Blvd.
Los Angeles, CA 90012
RE: Employee
Einployee# :
Claim#
Dept#/Name :
DOl
P+S Recd. :
Dear Return to Work Coordinator:
Sally Smith
000000
1000-00-0000 ..
000770/County of Los Sheriff's Department
11/01/04
12/23/04
The following temporary work restrictions are established on medical and related data.
Their purpose is to. prevent further injury to the employee and minimize additional .--
County liabilty. These restrictions \ should be strictly observed on any and an.s
assignments.
TïËniU:iORÄRYWORK RESTFiiC,.-IÖÑS
restrictions ar~: . . .
Based on Dr. Sobol's Permanent and Stationary (P&S) report of 8/25/04, the
Knee: No very heavy lifting (contemplates the individual has lost approximately
one quarter of her pre-injury capacity for lifting.
Please schedule an interactive meeting with the employee to discuss these restrictions.
For the employee's protection, please make the restrictions part of their confidential.
medical file. .
A job offer should be made utilzing the' RU-94 or the DWC-AD 10133.53 (for
injuries occurring on or after 1/1/04).
A permanent work restriction letter wil be sent following final resolution of this claim.
Sincerely,
Claims Adjuster
cc: Employee
File
l

Date
Return to Work Coordinator
3333 Wilshire Blvd.
Los Angeles, CA 90010
RE: Employee
Employee# :
Claim#
Dept#/Name :
DOl:
Dear Return to Work Coordinator:
Sally Smith
00000000
1000-00-0000
County of Los Angeles Sheriff's Department
11/01/03
The above employee's Workers' Compensation claim has been settled and a
permanent disabilty rating has been assigned.
The following work restrictions are established on the medical and related data upon
which this rating was based. These restrictions should be strictly observed on any and
allassignmentstoâvoidaggravatiònof the-existing-disability, re"'injuryor creation of a
hazard for other employees.
PERMANENT WORK RESTRICTIONS
Based on the award of 6/1104 the employee is precluded from very heavy lifting.
This contemplates the individual has lost approximately one-quarter of her preinjury
capacity for lifting.
Please inform the employee of these restrictions in writing, and for his/her protection,
make it part of the employee's confidential medical file.
Sincerely,
Claims Adjuster
cc: File

" '
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County of Los Angeles
EQUAL EMPLOYMENT
OPPORTUNITY FOR
TUE DISABLED
PREPARED BY THE OFFICE
OF AFFIRMATIVE ACTION
COMPLIANCE
REVISED
FEBRUARY 1992

Section
III.
A.
B.
C.
D.
E.
A.
B.
V.
A.
B.
C.
D.
E.
F.
G.
VI.
I. INTRODUCTION
. Purose
. Objective
II. LEGAL AUTHORITY
. Federal Law
.
.
State Law
County Policy
CONTENTS
AFFIRMATIVE ACTION PROGRAM
Action Plans
Goals and Timetables
Monitoring and Evaluation
Supportive Programs
Definition of the Disabled
IV. MEDICAL EXAMINATIONS
Preplacement Medical Screening
Medical Examinations of Existing Employees
REASONABLE ACCOMMODATION
Qualification for Reasonable Accommodation
Examples of Reasonable Accommodation
Evaluating the Need to Provide Reasonable Accommodation
Processing Requests for Reasonable Accommodation
Denial of Request for Accommocation
Employment Issues
Return to Work
CONCLUDING COMMENTS

I. INTRODUCTION
PURPOSE
Ton ensure that the County of Los Angeles, provides Equal Employment
Opportunity/Affirmative Action to all Disabled applicants and County employees.
OBJECTIVE
. To enumerate existing laws, regulations and policies governing
employment to the Disabled.
. To incorporate the Disabled into the existing County Affirmative Action
program.
. To ensure that reasonable accommodation is provided to all Disabled
applicants and employees.

II. LEGAL AUTHORITY
FEDERAL LAW
The Rehabilitation Act of 1973 implemented a national policy against
discrimination on the basis of disabilty and was intended to promote the
rehabilitation and employment of disabled individuals. The Act has several
sections relating to employment of the Disabled.
Section 504 is of particular importance to the County. It provides that qualified
individuals with disabilities shall not be excluded from participation in, denied the
benefit of, or be subjected to discrimination under any program or activity
receiving Federal financial assistance. This section also requires employers to
make reasonable accommodations to applicants and employees with disabilities.
The Americans with Disabilities Act (ADA) became law in July 1990. The ADA
extends federal civil rights protection in several areas to people who are
considered 'disabled'. The act states its purpose as providing 'a clear and
comprehensive national mandate for the elimination of discrimination against
individuals with disabilities.'
The ADA seeks to dispel stereotypes and assumptions about disabilties, and to
assure equality of opportunity, full participation, independent living and economic
self-suffciency for disabled people. To achieve these objectives, the law
prohibits covered entities from excluding people from jobs, services, activities or
benefits based on disability. The law provides penalties for discrimination.
Title i of the ADA makes it illegal for any employer to discriminate against
individuals with a disability and required that reasonable accommodation be
provided to the Disabled in employment. Effective July 26, 1992 the U.S. Equal
Employment Opportunity Commission has the enforcement responsibilities for
Title I (attachment I).

STATE LAW
In addition to Federal Laws, State of California Government Code Section 19230,
as amended, requires that disabled persons shall be employed on the same
terms and conditions as the non-disabled, unless it is shown that the particular
disability is job related. This code section also requires that reasonable
accommodation be provided to otherwise qualified disabled applicants and
employees.
COUNTY POLICY
In compliance with Federal and State laws the County of Los Angeles has
established the following policy:
. Disabled applicants and employees wil not be discriminated against on the
basis of their disability.
. Voluntary affirmative action wil be taken to ensure that the disabled have
equitable representation in the County work force.
. Disabled persons are to be employed on the same basis as non-disabled
persons, unless it can be demonstrated that the job in question requires the
individual to meet certain bona fide occupations qualifications in order to
perform the essential duties of the job.
. Departments shall make reasonable accommodation to the known physical or
mental limitations of an otherwise qualified disabled applicant or employee.

III. AFFIRMATIVE ACTION PROGRAM
The goals of the County's Affirmative Action Program are to eliminate all artificial
barriers in employment and to achieve a work force that is balanced for ethnic
minority groups and women based on their representation in the County external
population and their availability. The Disabled are now on affirmative action
target group and the above goals are applicable.
In accordance with existing County Affirmative Action policy, the needs of the
Disabled must be incorporated into the following personnel practices:
A. Action Plans
1. Recruitment
a. recruitment procedures shall be reviewed and analyzed to
identify and eliminate discriminatory barriers:
b. Objective measures shall be established to analyze and monitor
the recruitment and appointment process;
c. Any persons involved in the employment process shall be
trained to use objective standards and support affirmative action
goals;
d. Programs to affirmatively recruit for all jobs where
underutilzation has been identified shall be instituted.
2. Selection
a. To insure that selection standards and procedures do not
discriminate, but instead contribute toward affirmative action
goals, a careful review and evaluation of every step of the
selection procedure is necessary. This review and evaluation
shall consider, but not be limited to the following:
. Job descriptions;
. Minimum requirements;
. Recruitment Sources;
. Application forms and pre-employment inquiries;

. Written examinations;
. Interview Procedures:
. Hiring criteria;
. Physical examinations;
. Probationary performance evaluations;
. Any other standard which qualifies or disqualifies persons for
employment, promotion, and training.
b. Job-related, validated standards for selection.
. Selection standards which adversely affect individuals on the
basis of race, color, religion, sex, national origin, age or
disabilty shall be eliminated unless they can be
demonstrated to be practically useful and job-related. Jobrelated
selection standards with adverse effect shall be used
only when no alternative, less discriminatory job-related
standards are available.
. To ensure that selection procedures remain nondiscriminatory,
they shall be reviewed and evaluated on a
continuing basis.
3. Upward Mobility
All format and informal practices affecting job assignment,
transfers, and promotion and training for jobs at all levels shall be
reviewed and evaluated to ensure their job relatedness. All artificial
barriers to mobility shall be eliminated. In addition, remedial
affirmative action programs shall be developed and implemented
for employees who are members of an "adversely affected class."
An "adversely affected class" is comprised of those who have
suffered and continue to suffer effects of past discrimination.
4. Benefits and Conditions for Employment
All benefits and conditions of employment shall be reviewed ad
evaluated to ensure that they are available without regard to race,
color, religion, sex, national origin, age or disability to all
employees. Included are:
. Medical and hospital benefits;
. Accident and life insurance;

. Retirement benefits;
. Leave of absence;
. Other, terms conditions and privileges of employment.
5. Neççative Personnel Actions
All negative personnel actions (terminations of any kind and for any
reason, reductions, suspensions, undesirable reassignments and
transfers, and any disciplinary action) will be reviewed and
evaluated to determine if they have a disparate effect on minorities,
women, and the disabled. As part of the review and evaluation
process, a monitoring system wil be developed to record all
negative personnel transactions which affect minorities, women, or
other members of an adversely affected class.
6. Rules and General Practices
All formal and informal rules and general practices related to
employment wil be reviewed to ensure consistency with the policy.
B. Goals and Timetables
The affirmative action program of the County shall include goals and
timetables. Goals and timetables consist of specific commitments to
appoint a certain number of minorities, women and the disabled to
specified classifications within a designated period of time. These goals
shall be based on considerations of underutilization.
1. Priority Actions
Highest priority shall be given to those actions which are necessary
to correct instances of obvious imbalance and/or where neither lack
of availability or any other factor is an obstacle to the immediate
implementation of a solution.
2. Lonçç-ranççe Goals
Long-range goals shall be developed for the County government
work force as a whole and for each significant organizational unit
within it. Such goals shall be as specific as necessary, including
but not limited to those for individual classifications. The ultimate
objective is a reasonably balanced work force overall, and at all
levels. All long-range goals shall establish the minimum
reasonable time periods within which they are to be achieved.

3. Annual Intermediate Tarqets
Once long-range goals have been established, specific numerical
annual targets shall be developed in order to reach the goals within
the indicated time frame. Annual targets shall be framed and
adjusted to achieve the relevant long-term goal and take into
account such factors as vacancies due to anticipated turnover,
expansion or contraction of the work force due to economic factors,
availability of persons with the required skils, and other similar
considerations.
c. Monitoring and Evaluation
Departments shall establish an internal reporting system to continually
audit, monitor and evaluate progress. This system will document all
significant personnel transactions and indicate responsibilty and
accountability.
D. Supportive Programs
Where necessary, departments should develop programs supportive of
affirmative action efforts. These programs shall include, but not be limited
to the following:
. Training for management and supervisors;
. Liaison with racial/ethnic communities, women and the Disabled.
. Career counseling.
E. Definition of the Disabled
In accordance with the American with Disabilities Act of 1990, the County
of Los Angeles defines a qualified Disabled individual as a person who:
(1) has a physical or mental impairment which substantially limits one
or more major life activities; (2) has a record of such an impairment, or;
(3) is regarded as having such an impairment.

1. Physical or mental impairment encompasses, but is not limited to:
a. Any physiological disorder or condition, cosmetic disfigurement, or
anatomical loss affecting one or more of the following body
systems: neurological, musculoskeletal, sense organs, respiratory,
speech organs, cardiovascular, reproductive, disgestive,
genitourinary, hemic, lymphatic, skin and endocrine; or any mental
or psychological disorder, such as mental retardation emotional or
mental ilness and specific learning disabilities.
b. Major life activities means functions such as caring for one's self
performing essential tasks, walking, seeing, hearing, speaking,
breathing, learning and working.
2. Has a record of such an impairment means a history, or has been
classified as having a mental or physical impairment that substantially
limits one or more major life activities.
3. Is regarded as having such an impairment means (1) having a physical
or mental impairment that does not substantially limit a major life
activity but being treated by an employer as having such an
impairment; (2) having a physical or mental impairment that
substantially limits major life activities only as a result of the attitudes of
others toward such impairments; or (3) not having an impairment but
being treated by an employer as having an impairment.
4. If there is a question regarding what constitutes a 'qualified disabilty'
contact the OAAC for clarification.

iv. MEDICAL EXAMINATIONS
Title I, Section 102 (c) of the American with Disabilities Act (ADA) prohibits
discrimination in medical examinations and inquiries.
A. Preplacement Medical Screening
1. Employers are prohibited from asking applicants whether they have a
disability or inquiring as to the nature or severity of a disability.
However, an employer may ask an applicant if he/she can perform a
job related function.
2. A medical examination can be performed once an offer of employment
has been made but before the applicant starts to work.
3. The employer may condition the offer of employment based on the
results of the medical examination.
4. This medical examination must be given to all candidates being offered
employment in the specific classification.
5. Information obtained from the medical examination must be maintained
as a separate, confidential medical record.
6. The employer (employing department) may be advised of necessary
work restrictions and possible accommodation, and first aid and safety
personnel may be advised if the disability might require emergency
treatment.
These requirements are consistent with current County policy. County
departments should refrain from asking applicants whether they have any
medical condition or history of treatment for any medical condition. An offer of
employment must be made to an applicant before a medical examination is
scheduled. This examination must take place before the individual starts work.
For emergency appointments made under Civil Service Rule 9.03, the department
should be aware that once the individual begins work, the department has
waived its right to require a medical examination. Further, departments which
routinely allow applicants to start work pending medical examination may be
jeopardizing their right to require medical examinations of any future applicants
for the specific classification.

B. Medical Examinations of Existing Employees
ADA allows employers to offer and conduct voluntary medical
examinations of employees as part of an employee health program. ADA
further allows employers to make inquiries into the ability of an employee
to perform job related functions. The Cöunty may continue to utilize Civil
Service Rule 9.07 and request medical reevaluations to determine on
employee's continuing ability to perform his/her job.
1. It is incumbent upon the department requesting a reevaluation to
document the need for the examination and describe how the
employee's job functioning is being impaired or otherwise affected.
2. The medical reevaluation, as it has always done, will focus on the
specific job duties which the employee seems unable to perform and
the medical condition(s) which may be affecting the employee's ability
to function.
3. ADA requires the department to provide reasonable accommodation
for work restriction established by the OHS as the results of
reevaluation.
Questions about medical examination, both preplacement and
reevaluation, should be directed to the Administrator or the Associate
Administrator of the Occupational Health Service at (213) 974-2658 OR
(213) 974-2641 respectively.

v. REASONABLE ACCOMMODATION
Reasonable accommodation is an adjustment made to the application/
examination process, the job duties, or the work .place/environment to enable a
qualified applicant/employee with a disability to perform the essential duties of
the position and to take part in all aspects of the employment process. This
includes employees who are returning to work after an industrial or non-industrial
injury.
In general, an accommodation is any change in the work environment or in the
way things are customarily done that enables an individual with a disability to
enjoy equal employment opportunities. There are three categories of reasonable
accommodation. These are (1) accommodations that are required to ensure
equal opportunity in the application process; (2) accommodations that enable the
employer's employees with disabilities to perform the essential functions of the
position held or desired; and (3) accommodations that enable the employer's
employees with disabilities to enjoy equal benefits and privileges of employment
as are enjoyed by employees without disabilities.
A. Qualification for Reasonable Accommodation
A person with a disability who meets the definitions of a handicapped
person as outlined in Section III.E. of these guidelines.
B. Examples of Reasonable Accommodation
1. Assisting candidates with a disability to equitably compete with nondisabled
candidates in the civil service examination process. Note: Do
not discuss accommodation on the job until a hiring commitment has
been made.
2. Modifying existing equipment or providing specialized equipment that
will allow the disabled employee to perform the essential duties of the
job.
3. Restructuring job duties to allow a disabled employee to perform the
essential duties of the job.
4. Removing physical barriers to allow the disabled to access test sites
and the work place.

c. Evaluating the Need to Provide Reasonable Accommodation
Request for accommodation should be considered on a case-by-case
basis. Do not attempt to generalize about a person's disability and the
type of accommodation needed. Departments must analyze the situation
relative to the individuals need and make a decision to deny or approve
the request after obtaining all necessary information. In all cases, the
applicant or employee should be consulted before any accommodation is
provided. Not all disabled individual want or need accommodation.
1. Decision Makinq Process - Departments Should:
. Determine the tasks necessary to participate in the examination or
the essential functions of the job to be performed. Review the class
specification and examination elements to ensure that they do not
adversely discriminate against the Disabled without being job
related.
. Obtain information concerning the person's specific limitations and
how they prevent him/her from participating in the examination or
performing the essential duties of the job.
. Consult with the applicant/employee to determine what
accommodation would be most effective in allowing him/her to
participate in the examination or in performing the essential duties
of the job.
. Determine what effect the accommodation will have on the
department's operation and employee's performance, and whether
the accommodation gives the disabled person the opportunity to
function or compete on a more equal basis with non-disabled
persons.
D. Processing Requests for Reasonable Accommodation
Periodically, applicants/employees with disabilities will require reasonable
accommodation for completing the application/examination process or in
performing the essential duties of the job. This also applies to employees
who become disabled as a result of an industrial or non industrial injury.
The OAAC has developed form AAP-22 "Reasonable Accommodation

Request" (attachment II) for completion when an applicant/employee
makes a request. A copy of AAP-22 must be forwarded to the OAAC prior
to the department's action. The information on this form is confidential
and should not be made available to any personnel other than those
involved in rendering a determination as to the merit of the
accommodation request. .
Each department is responsible for establishing a procedure that
adequately addresses the need to respond to an applicant/employee's
accommodation request in a timely manner and for forwarding form AAP-
22 to the OAAC. The County Coordinator for Persons with Disabilities will
review each request to ensure that the proposed approval or denial action
is warranted.
1. Civil Service Examinations
The OACC has drafted standard equal employment opportunity
language (attachment Ill) for use on all departmental employment
bulletins. The OAAC strongly recommends that all departments use
this language, particularly with respect to the disabled to ensure
compliance with County policy and the Americans with Disabilties Act
of 1990.
Reasonable Accommodation may be requested for one or all phases of
the examination process. Requests may include, but are not limited to
the following:
a. Make Test Sites Accessible
If a thorough review of the examination facilty reveals barriers
(stairs, inaccessible restrooms, etc.) then stes should be takep to
remove those barriers. If removal of the barriers in not feasible,
then using an alternate facility which is accessible should be
considered.
b. Make Written Test Accommodations
Many individuals with disabilities can not use regular test
procedures; it may be necessary to accommodate with certain

disabling conditions. The objective is to eliminate any artificial
barriers which may prevent the disabled person from demonstrating
his/her capabilities during the exam process.
c. Test Administration
. Departments may not administer examinations that screen out
groups.
. Allowing persons with disabilities additional time to complete the
test.
. Using proctors that are trained to administer tests to persons
with disabilties.
. Providing readers or written test in Braille or large print for the
visually impaired.
. Providing sign language interpreters for persons with hearing
impairments.
d. Test Content
. Departments may not administer examinations that screen out or
tend to screen out persons with disabilities, unless the test
content or methodology is demonstrated to be job related.
. Examinations that adversely affect the disabled must be modified
to eliminate those elements that have disproportionate effects
that are not job related. In some cases, a job validation study to
evaluate the job relatedness of each part of the examination may
be required.
2. On the Job
Changes in the work environment may be needed to allow a disabled
person to perform the essential job duties. Providing reasonable
accommodation on the job include, but are not limited to the following:

a. Modification of the work environment to allow a person with a
disabilty to perform his/her duties can be simple, and most
times inexpensive. For example:
. Rearranging files or shelves for accessibility by wheelchair
occupants.
. Placing Braille labels or tactile cues on shelves so blind
employees can identify contents.
. Widening access areas between fixtures to allow room for
wheelchairs.
. Raising or lowering equipment to provide comfortable working
heights.
. Moving equipment controls or adopting them for hand or foot
operations.
. Installing special holding devices on desks, machines or
benches.
. Providing a speaker telephone or cordless telephone equipment
with headphones.
. Installng telecommunication devices (TOO's) or telephone
amplifiers for the hearing impaired.
b. Job restructuring to allow an otherwise qualified disabled
employee to perform the essential duties of the job. This
involves identifying those functions that make a job incompatible
with a workers' disability and, if possible, eliminating those
functions, so that the capabilities of the person may be used to
their fullest extent. Job restructuring does not eliminate the
essential functions of the job. Rather, any changes made are
those which enable the person to perform essential functions.
This is accomplished by changing job content and/or by isolating
and eliminating non-essential functions through reassignment.

The supervisor should obtain information about the limitations of
the employee and then conduct a careful job analysis to identify
the exact demands of the position to determine how it might be
restructured. Persons who currently perform the job should be
included in the analysis process to accurately identify the
essential and non-essential functions of the position.
c. Providing assistive devices to enable disabled persons to
perform tasks they would not otherwise be able to perform.
Assistive devices may increase independence, quantity, quality,
and efficiency in their work. Before purchasing any equipment,
the disabled employee should be consulted as to the specific
need. Examples of assistive devices include, but are not limited
to:
. Special telephone equipment
. Talking calculators
. One handed typewriters
. Closed circuit televisions
. Tele-communication devices for the deaf (TOO)
. Specially designed desks
. Voice activated computers
d. Access to the Work Place
Architectural and program accessibility are governed by
statutes such as the Architectural Barriers Act of 1968 as
amended, and the ADA Title i of the ADA states: "The term
reasonable accommodation may include making existing
facilities used by employees readily accessible to and usable by
individuals with disabilities."
Physical and/or structural changes should be made in order to
provide an accessible work environment. Elimination of access
barriers can be accomplished by installing ramps, widening
doorways and providing handrails and parking.

E. Denial of Request for Accommodation
Federal law requires that employers make reasonable accommodation to
the known physical and/or mental limitations of an otherwise qualified
applicant or employee with a disability; unless the employer can clearly
dèmonstrate that the accommodation would impose an undue hardship on
the operation of its program. Undue hardship is the only legitimate reason
for denying reasonable accommodation that would allow a disabled
employee to perform the essential functions of the job.
1. Factors to Consider in Determininq Undue Hardship
a. The overall size of the department with respect to the number of
employees, number and type of facilities and size of budget.
b. The type of operation, including the composition and structure of the
department's workforce.
c. The nature and cost of the accommodation needed. In every case
of undue hardship, cost is the final factor to be considered. Prior to
purchasing any equipment, all alternatives should be explored to
determine if the reasonable accommodation proposed is the most
cost effective.
2. Appeal Process
If a request for accommodation by a Handicapped applicant/employee
is denied he/she must be informed of his/her right to appeal the action
in accordance with Civil Services Rules 4, 6.07 and 25.
F. Employment Issues
To eliminate artificial barriers in the hiring or promotion of persons with a
disabilty, all employment decisions must be made on the basis of whether
a candidate can perform the "essential functions" of a position either
unaided or with reasonable accommodation.

1. Essential Job Functions
According to the ADA job functions may be considered "essential"
when they are fundamental to the position the individual holds or
desires. Specifically, a function may be considered essential if the
position exists to perform that function, if there are a limited number of
employees among whom the performance of that job function can be
distributed, and/or the function is highly specialized so that the
incumbent in the position is hired for his or her expertise or abilty to
perform the particular function. (For the purposes of this Guide, a
"position" is defined as the particular set of duties or functions
performed by an individual employee; the term "job" has the same
meaning as "classification.")
a. Documentation
In accordance with the ADA, specific documentation should exist to
show that:
. The "essential functions" apply to the positions in question,
. The functions involve non-trivial amounts of time in their
performance; and
. The consequences of non-performance of the functions would
have detrimental consequences for the organization.
b. Examination Bulletins
A published bulletin for an examination should describe the
essential job functions for the positions to be staffed by means of
the examination. Because there may be an alternative means by
which a person with a disability can perform the job, the essential
functions should describe the work that gets done (e.g., calculating
benefits using a 10-key adding machine, discussing contacts with
vendors.)

The example duties in the County's Class Specifications should not
automatically be used to describe essential job functions in bulletins
for two reasons: (1) the duties may specifically work processes or
behaviors that inadvertently discourage applications from persons
with disabilities and (2) the duties may not be essential for all or
most of the positions affected by the particular examination. .
In some cases, however, the duties in the Class Specifications may
adequately represent the job functions (Le., when the statements
describe work products or results, and when care has been taken
to ensure that the duties are truly essential for the vacancies in
question.)
c. Levels of Analysis
G. Return to Work
When a broad classification (e.g., intermediate typist clerk) is the
focus of analysis, essential functions may need to be studied at two
levels.
. The first level may consist of the job functions that apply to the
entire classification (e.g., encoding/copying information from
written forms to computer data bases).
. The second level may consist of the functions that apply to
specific positions or subgroups of positions within the
classification (e.g., providing assistance at a public counter).
Evaluation of requests for reasonable accommodation in the
examination and on the job should be made with respect to both
the general and the position-specific functions.
The following information wil assist Department's Return-To-Work Units in
complying with ADA requirements. Return-to-Work Coordinators (RTWC)
should follow the procedures set forth in Civil Service Rule 9.08, which are
consistent with the ADA.
These procedures are to be applied in both industrial as well as nonindustrial
injury cases, and in other cases that meet the definition of
"qualified disability" under ADA (see section III. E.).

Whenever a request is received for "reasonable accommodation" the
RTWC should process the request in accordance with section V., D. and
conduct the following:
1. Review the Essential Functions of the job (see section V., F.)
2. Promptly review status of medical report(s) and determine medical
status of returning employee as being:
. Competent
. Questionable
3. If a medical report is questionable or unclear in a non-litigated case, it
may be appropriate to refer the employee to Occupational Health
Services (OHS) for a medical re-evaluation. If litigated, consult with a
Workers' Compensation Representative for a rush medical referraL.
4. When the employee requests reasonable accommodation, ask the
employee what he or she thinks is reasonable under his/her particular
circumstances, and consider the employee's input (see section V.).
5. In accordance with Civil Service Rule 9.08, the first three options
should be considered in order.
6. If there is a dispute regarding ADA regulations with respect to
employment, the OAAC will have the authority to resolve the issues.
OAAC wil need to see the full documentation on the attempts to make
reasonable accommodations. Any consideration on separating an
employee from the system under CSR 9.08 still requires consultation
with Disability Benefits Division/RIMA and the OACC.
a. Options for Employees who can not be accommodated
If a department can not reasonably accommodate a qualified
Individual with an industrially caused disability the individual may
be eligible for vocational rehabiltation under Labor Code Section
139.5. If the disability was non-industrially caused the employee
may be eligible for Long Term Disabilty, retirement and assistance
from the State Department of Rehabilitation.

Vi. Concluding Comments
This revision of the Equal Employment Opportunity for the Disabled manual was
made in conjunction with the American with Disability Task Force composed of: .
CAO Policy & Support Division
CAO Occupational Health
CAO Risk Insurance Management Agency (RIMA)
County Counsel
OAAC Affirmative Action Programs Section
OAAC Test & Research Section
We hope that these guidelines have provided useful information on the County's
requirements for providing equal employment opportunity to disabled applicants
and employees. Furthermore, we encourage and solicit your suggestions and
comments which may improve these guidelines. Please direct your comments
to:
Office of Affirmative Action Compliance
County Coordinator for Persons with Disabilities
500 W. Temple Street, Rm. 780
Los Angeles, CA 90012
Voice: 213-974-1087
TDD: 213-974-0911

Reasonable Accommodation Resources
• Equal Employment Opportunity Commission (EEOC) Website
Employers and individuals with disabilities wishing to learn more about reasonable
accommodation can contact the EEOC at (202) 663-4691 (voice) and (202) 663-
7026 (TTY). General information about reasonable accommodation can be found on
EEOC’s website, www.eeoc.gov/policy/guidance.html (Enforcement Guidance on
Reasonable Accommodation and Undue Hardship Under the Americans with
Disabilities Act; revised 10/17/02. This website also provides guidances on many
other aspects of the ADA.
• Job Accommodation Network (JAN)
The government-funded Job Accommodation Network is a free service that offers
employers and individuals ideas about effective accommodations. The counselors
perform individualized searches for workplace accommodations based on a job’s
functional requirements, the functional limitations of the individual, environmental
factors, and other pertinent information. JAN can be reached at 1-800-526-7234
(voice or TDD); or at www.jan.wvu.edu/soar.

Comparison of Major Distinctions in
California and Federal Employment Disabilty Provisions
Provisions included in the Provisions included in the
CA Fair Employment and Housing American with Disabilities Act
Act; (FEHA) and Fair Employment (ADA), Equal Employment
& Housing Commission (FEHC) Opportunity Commission
Decisions and Regulations (EEOC) Regulations;
Federal Court Decisions
Covered Having fiye or more employees for Private employers with 15 or more employees;
Employers complaints inyolYing physical or mental state and local governments regardless of size.
disability or medical condition.
Nonprofit, religious organizations engaged are
Having one or more employees for covered by the ADA but they may give
complaints inyolYing harassment based on employment preference to people of their own
mental or physical disability. religion or religious organization. However, they
may not discriminate on the basis of disability
Excludes religious associations or against members or nonmembers. Executive
corporations not organized for profit. agencies of the US government are excluded from
the ADA.
Definition of The FEHA forbids employment discrimination. The ADA defines "qualified indiYidual with a
"Disability" against an indiYidual because of his or her disability" as an individual with a disability who
physical disability, mental disabllity, or can perform the essential functions of a job with or
medical condition. without reasonable accommodation.
A person is recognized as "disabled" if A person is recognized as "disabled" if he/she:
he/she:
. has a physical or mental impairment that
. has a physical or mental disability that. substantiallv limits one or more of his/her
limits (I.e., it makes the achievement of maior life actiYities (caring for one's self,
the major life activity diffcult) one or performing manual tasks, walking, seeing,
more maior life actiyities (construed hearing, speaking, breathing, learning, and
broadly to include physical, mental, working); or
and social activities and working); or
. has a history of such an impairment . has a record of such an impairment; or
known to the employer; or
. is incorrectly reaarded or treated as . is reaarded as having such an impairment.
having or having had such an
impairment; or
. is reaarded or treated as haYing or
having such an impairment that has no
presently disabling effects but may
become a qualifying impairment in the
futu re.
"Physical disabilities" include, but are not
limited to, any physiological disease,
disorder, condition, cosmetic disfigurement
or anatomical loss that affects one or more
of the following body systems:
neurological, immunological,
musculoskeletal, special sense organs
(including speech organs), respiratory,
cardioyascular, reproductive, digestiye,
aenitourinarv. hemic and Ivmphatic skin

Definition of
"Disability"
and endocrine systems.
"Medical Condition" is defined as including
(continued) any health impairment associated with a
diagnosis of cancer when competent
medical eyidence indicates that the cancer
victim has been cured or rehabilitated. It
also includes certain genetic characteristics
as defined in the statute.
"Mental disabilties" include, but are not
limited to, any mental or psychological
disorder or condition, such as mental
retardation, organic brain syndrome,
emotional or mental illness, specific
learning disabilities, or any other mental or
psychological disorder or condition that
requires special education or related
services.
Exclusions from . Sexual behayior disorders (not . Persons who currently use drugs illegally
Definition of currently defined); or (those not currently using illegal drugs but
Physical and
Mental Disability
.
.
Compulsive gambling, kleptomania,
pyromania; or
Psychoactiye substance use disorders
resulting from the current unlawful use
of controlled substances or other
drugs.
.
.
in rehabilitation from such use may be
covered);
Homosexuality and bisexuality are not
considered "impairments" or "disabilities";
Transvestism, transsexualism, pedophilia,
exhibitionism, yoyeurism, gender identity
disorders not resulting from physical
.
impairments; or
Compulsiye gambling, kleptomania, or
.
pyromania; or
Psychoactiye substance use disorders
resulting from current illegal use of drugs.
Mitigating Mitigating measures, such as assistive Mitigating measures are considered in
Measures devices, prosthesis, medication, etc., are not determining if a major life activity is "substantially
considered in determining whether a limited."
condition "limits" a major life activity, unless
the mitigating measure itself limits a major
life activity.
"Working" as a . Working is considered a major life activity . EEOC regulations state that working is
Major Life along with physical, mental and social considered a major life actiYity along with
Activity activities. caring for one's self, penorming manual
tasks, walking, seeing, hearing, speaking,
. To be limited in the major life actiYity of breathing, and learning.
working, an individual need only be
limited in penorming the requirements of . To be substantially limited in the major life
a single, particular job. activity of working, an indiyidual must be
significantly restricted in the ability to
penorm either a class of jobs or a broad
range of jobs in various classes as
compared to the average person having
comparable training, skills, and abilities.
The inability to penorm a single, particular
job does not constitute a substantial.
limitation in the major life activity.

Employment Pre-Offer: An employer may not ask or Pre-Offer: An employer may not ask or
Medical or
Psychological
Inquiries and
Examinations
require a job applicant to take a medical
examination before making a job offer.
Absent a request for reasonable
accommodation during the hiring process, it
cannot make any pre-employment inquiry
about a disabilty or the nature of the
require a job applicant to take a medical
examination before making a job offer.
Absent a request for reasonable
accommodation during the hiring
process, it cannot make any pre-
employment inquiry about a disability or
severity of a disability. An employer may the nature of the severity of a disability.
inquire into the ability of an applicant to An employer may ask questions about
perform job-related functions. the ability to perform specific job
functions and may, with certain
Post Offer: An employer may require a limitations, ask an indiyidual with a
medical or psychological examination or disability to describe or demonstrate how
make a medical or psychological inquiry of a
job applicant after an employment offer has
he/she would perform these functions.
been made but prior to commencement of Post-Offer: An employer may condition a job
employment duties, provided that the offer on the satisfactory result of a post-offer
examination or inquiry is job-related and medical examination or medical inquiry if this is
consistent with business necessity and that required of all entering employees in the same
all entering employees in the same job job category. A post-offer examination or inquiry
classification are subject to the same does not have to be job related or consistent with
examination or inquiry. business necessity. However, an employer may
not refuse to hire an individual with a disability
Post-Hire: An employer may require based on the medical examination results unless
examinations and inquiries if it can show the reason for rejection is job-related and justified
such to be job-related and consistent with
business necessity. An employer may
by business necessity.
conduct yoluntary medical examinations, Post-Hire: After a person starts work, a medical
including yoluntary medical histories, which examination or inquiry of an employee must be
are part of an employee health program job related and consistent with business
ayailable to employees at that worksite. necessity. Employers may conduct employee
medical examinations where: there is evidence of
a job performance or safety problem, required by
federal law, necessary to determine fitness to
perform a particular job, and where part of a
yoluntary examination that is part of an employee
health program.
Genetic An employer may not test an applicant or Not explicitly included as a covered disability.
Characteristics employee for the presence of a genetic May fall within the category of a "perceived
characteristic. disabilty" in some cases.
Reasonable Generally, an employer must make EEOC guidelines outline steps that the employer
Accommodation;
Exceptions
reasonable accommodation for an employee
or for an applicant with a known Dhvsical or
mental disabiltv. This requirement does not
and employee may take to arriye at an
accommodation.
apply to an applicant or employee with a "Good faith" is interpreted in a federal court
known medical condition. decision as it applies to the EEOC guidelines.
Requires a "good faith, interactive process" Under the ADA, employers wil not be liable for
to determine an accommodation. compensatory and punitive damages if it has been
Incorporates the EEOC guidelines for engaged in "good-faith efforts" to identify a
defining an "interactive process." California possible accommodation.
courts have yet to define "good faith."

Reasonable To deny an accommodation, an employer "Undue hardship" defense proYisions to deny an
Accommodation; must prove that: accommodation are generally the same under the
Exceptions
1) the accommodation poses an undue
ADA.
(continued) hardship on the employer; An employer may refuse to hire an employee if
2) the employee cannot penorm the the selection standards and criteria are job related
essential job functions even with and consistent with business necessity and:
accommodation;
3) the accommodation presents a danger to 1) no accommodation exists that permits the
the disabled employee or others; person to penorm essential job functions;
4) the employee would not meet a bona 2) the person poses a direct threat to the safety
fide occupational qualification; of others.
5) Another statutory requirement (e.g.
safety, OSHA, etc.) preempts the FEHA
proYision; or
6) Another affirmatiye defense under FEHA
applies.
###
DFEH-208DH (3/02)

Disability Under the Fair
Employment & Housing Act:
What you should know
about the law
California Department of
Fair Employment & Housing

Disabilty Under the Fair Employment and Housing Act:
What You Should Know About the Law
In 1974, California passed its first law intended to ensure that individuals with disabilities
are protected in the workplace. Since then, California has been at the forefront of
guaranteeing that persons with disabilities have equal access to employment.
This guide is intended to highlight and summarize workplace disability laws enforced by
the California Department of Fair Employment and Housing (DFEH). It will familiarize
you with the content of these laws, including recent changes and amendments to state
statutes and attendant accommodation responsibilities. It should not be relied upon as
a definitive statement of the law. For answers to your particular questions, you should
consult an attorney or employment relations specialist for advice. You can also contact
DFEH for information at 1-800-884-1684.
California disability laws are intended to allow persons with disabilities the opportunity
for employment. To meet this goal, California's laws have historically offered greater
protection to employees than federal law. Yet, because most news coverage focuses on
actions taken by the U.S. Congress and court decisions interpreting the federal
Americans with Disabilities Act (ADA), many employees and employers in California are
not aware that California's laws are broader in many aspects. For example, the ADA
defines disability as "a physical or mental impairment that substantially limits one or
more major life activities." However, under California law, disability is defined as an
impairment that makes performance of a major life activity "difficult." Thus, under
California law, persons with a wide variety of diseases, disorders or conditions would be
deemed to have a disability who, under the definitions set forth in the ADA and the
United States Supreme Court's narrow interpretations of that statute, might not be
considered "disabled" and therefore denied protection.
A chart illustrating some of the differences between federal and state law is provided at
the back of this guide.
WHAT CHANGES DO I NEED TO KNOW ABOUT?
In 2000, the state legislature passed the Prudence K. Poppink Act that made significant
changes to the state's disability laws. It amended existing provisions of law and reemphasized
previous legal and policy positions. These legislative amendments took
effect on January 1, 2001. Some of the important changes are as follows:
. The Legislature found and declared that the laws of this state provide protection
independent of the 1990 ADA and has always afforded broader protection than
federal law.
. The definitions of mental and physical disability were amended to prevent
discrimination based on a person's "record or history" of certain impairments.
. Physical and mental disabilities include, but are not limited to, chronic or episodic
conditions such as HIV/AIDS, hepatitis, epilepsy, seizure disorder, multiple sclerosis,
and heart disease.

. The Legislature clarified that the definitions of physical and mental disability only
require a "limitation" upon a major life activity, not a "substantial limitation" as
required by the ADA. They further stated that when determining whether an
employee's condition is a limitation, mitigating measures should not be considered,
unless the mitigation itself limits a major life activity.
. "Working" is a major life activity regardless of whether the actual or perceived
working limitations implicate a specific position or broad class of employment.
Whereas, under the ADA, the mental or physical disability must affect a person's
ability to obtain a broad class of employment.
. An employer or employment agency cannot ask about a job applicant's medical or
psychological condition or disability except under certain circumstances. In addition,
it is illegal to ask current employees about these conditions unless the condition is
related to the employee's job.
WHAT DOES THE LAW REQUIRE OF EMPLOYERS?
An important aspect of complying with California law is knowing what is required by
state law. When it comes to applicants and employees with disabilities, the FEHA
generally requires two things of employers. Those requirements are:
1. Employers must provide reasonable accommodation for those applicants and
employees who, because of their disability, are unable to perform the essential
functions of their job.
2. Employers must engage in a timely, good faith interactive process with applicants or
employees in need of reasonable accommodation.
However, before engaging applicants or employees, the employer should have some
understanding of what constitutes a "disability" under state law. Before an applicant or
employee must be reasonably accommodated, he or she must establish that they have
a disability as defined under the Fair Employment and Housing Act.
WHAT IS A DISABILITY UNDER THE LAW?
The Fair Employment and Housing Act basically defines two categories of disability:
mental disability and physical disability. Each category contains its own specific
definitions. Additionally, under the FEHA, an employee with a "medical condition" is
also entitled to accommodation.
The following are the specific definitions of physical disability, mental disability, and
medical condition as outlined in the FEHA:
Physical Disability-Having any physiological disease, disorder, condition, cosmetic
disfigurement, or anatomical loss that affects one or more of several body systems and
limits a major life activity. The body systems listed include the neurological,
immunological, musculoskeletal, special sense organs, respiratory, including speech
organs, cardiovascular, reproductive, digestive, genitourinary, hemic and lymphatic, skin

and endocrine systems. A physiological disease, disorder, condition, cosmetic
disfigurement, or anatomical loss limits a major life activity, such as working, if it makes
the achievement of the major life activity difficult.
When determining whether a person has a disability, an employer cannot take into
consideration any medication or assistive device, such as wheelchairs, eyeglasses or
hearing aids, that an employee may use to accommodate the disability. However, if
these devices or mitigating measures "limit a major life activity", they should be taken
into consideration.
Physical disabiliy also includes a ny other health impairment that requires special
education or related services; having a record or history of a disease, disorder,
condition, cosmetic disfigurement, anatomical loss, or health impairment which is known
to the employer; and being perceived or treated by the employer as having any of the
aforementioned conditions.
Mental Disability-Having any mental or psychological disorder or condition, such as
mental retardation, organic brain syndrome, emotional or mental illness, or specific
learning disabilities, that limits a major life activity, or having any other mental or
psychological disorder or condition that requires special education or related services.
An employee who has a record or history of a mental or psychological disorder or
condition which is known to the employer, or who is regarded or treated by the employer
as having a mental disorder or condition, is also protected.
It should be noted that under both physical and mental disability, sexual behavior
disorders, compulsive gambling, kleptomania, pyromania, or psychoactive substance
use disorders resulting from the current unlawful use of controlled substances or other
drugs, are specifically excluded and are not protected under the FEHA.
Medical Condition-Any health impairment related to or associated with a diagnosis of
cancer or a record or history of cancer, or a genetic characteristic.
A "genetic characteristic" can be a scientifically or medically identifiable gene or
chromosome or an inherited characteristic that could statistically lead to increased
development of a disease or disorder. For example, women who carry a gene
established to statistically lead to breast cancer are protected under state law.
Keep in mind, however, that Government Code section 12940(0) makes it an unlawful
employment practice for an employer to subject, directly or indirectly, any applicant or
employee, to a test for the presence of a genetic characteristic.
In determining a disability, an employer may only request medical records directly
related to the disability and need for accommodation. However, an applicant or an
employee may submit a report from an independent medical examination before
disqualification from employment occurs. The report must be kept separately and
confidentially as any other medical records, except when a supervisor or manager
needs to be informed of restrictions for accommodation purposes or for safety reasons
when emergency treatment might be required.

WHAT CAN BE DONE FOR AN APPLICANT OR EMPLOYEE WITH A DISABILITY?
Once a disability that is protected under the law is established, an employer is obligated
to provide a reasonable accommodation unless the accommodation would represent an
undue hardship to the business operation.
In the process of determining a reasonable accommodation, an employer must enter
into a good-faith, interactive process to determine if there is a reasonable
accommodation that would allow the applicant or employee to obtain or maintain
employment. The first step of the "interactive process" is the determining the "essential
functions" of the position. When determining whether a job function is essential, the
following should be taken into consideration: (1) the position exists to perform that
function; (2) there are a limited number of employees available to whom the job function
can be distributed; or (3) the function is highly specialized.
Evidence of whether a particular function is essential includes the employer's judgment
as to which functions are essential; a written job description prepared before advertising
or interviewing applicants for the job; the amount of time spent on the job performing the
function; the consequences of not requiring the incumbent to perform the function; the
terms of a collective bargaining agreement; the work experiences of past incumbents in
the job; or the current work experience of incumbents in similar jobs.
Once an employer has evaluated the position and the essential functions of the position,
he or she should begin the process of determining reasonable accommodation by
engaging in good-faith interaction with the employee.
WHAT IS A REASONABLE ACCOMMODATION?
Reasonable Accommodation
Reasonable accommodation is any appropriate measure that would allow the applicant
or employee with a disability to perform the essential functions of the job. It can include
making facilities accessible to individuals with disabilities or restructuring jobs, modifying
work schedules, buying or modifying equipment, modifying examinations and policies,
or other accommodations. For example, providing a keyboard rest for a person with
carpal tunnel syndrome may qualify as a reasonable accommodation. A person with
asthma may require that the lawn care be rescheduled for a non-business day.
WHAT IS THE INTERACTIVE PROCESS?
Interactive Process
State law incorporates guidelines developed by the Equal Employment Opportunity
Commission in defining an "interactive process" between the employer and the
applicant or employee with a known disability.
The guidelines include: consulting with the individual to ascertain the precise job-related
limitations and how they could be overcome with a reasonable accommodation; and
identifying potential accommodations and assessing their effectiveness.

Although the preferences of the individual in the selection of the accommodation should
be considered, the accommodation implemented should be one that is most appropriate
for both the employee and the employer.
WHAT IS GOOD FAITH?
Good Faith
Federal courts have provided an interpretation of "good faith," essentially stating that an
employer and employee must communicate directly with each other to determine
essential information and that neither party can delay or interfere with the process.
To demonstrate good-faith engagement in the interactive process, the employer should
be able to point to cooperative behavior that promotes the identification of an
appropriate accommodation.
MUST AN APPLICANT OR EMPLOYEE ALWAYS BE ACCOMMODATED?
The FEHA does provide legal reasons an employer can permissibly refuse to
accommodate a request for reasonable accommodation from an applicant or employee.
One of the legal reasons is whether the accommodation would present an undue
hardship to the operation of the employer's business.
If an employer denies accommodation because it would be an "undue hardship," it must
be shown that the accommodation requires significant difficulty or expense, when
considered in the light of the following factors:
. The nature and cost of the accommodation needed;
. The overall financial resources of the facilities involved in the provision of the
reasonable accommodations, the number of persons employed at the facility, and
the effect on expenses and resources or the impact otherwise of these
accommodations upon the operation of the facility;
. The overall financial resources of the employer, the overall size of the business with
respect to the number of employees, and the number, type, and locations of its
facilities;
. The type of operations, including the composition, structure, and functions of the
workforce of the employer; and
. The geographic separateness, administrative or fiscal relationship of the facility or
facilities.
For example, an applicant with a severe vision impairment applies for employment with
a small market that has only four other employees. The applicant requires assistance to
work the register by having another employee present at all times. The business in
question would not have to provide the accommodation if, for example, it could not
afford the cost of the additional staff or could not afford the cost of remodeling to
accommodate two employees at the same time.

WHAT QUESTIONS MAY BE ASKED OF AN APPLICANT OR EMPLOYEE?
What questions may be directed to an individual depends, largely, upon whether the
individual is an applicant for a position or is currently employed by the employer.
Pre-employment Inquiries
Prior to employment, it is unlawful for an employer to require an applicant to attend a
medical/psychological examination, make any medical/psychological inquiry, make any
inquiry as to whether an applicant has a mental/physical disability or medical condition,
or make any inquiry as to the severity of the disability or medical condition.
However, an employer may inquire into the ability of an applicant to perform job-related
functions and may respond to an applicant's request for reasonable accommodation or
require a medical/psychological examination or make an inquiry of a job applicant after
an employment offer has been made but prior to the the start of employment provided
that the examination or inquiry is job-related and consistent with business necessity and
all new employees in the same job classification are subject to the same examination or
inquiry.
Post-employment Inquiries
If the individual is a current employee, the employer may not require any
medical/psychological examination of an employee or make any of the following
inquiries:
. Medical or psychological;
. Whether an employee has a mental/physical disability; or
. The nature or severity of a physical disability, mental disability, or medical condition.
However, an employer may require any examinations or inquiries that it can show to be
job-related and consistent with business necessity. Furthermore, an employer may
conduct voluntary medical examinations, including voluntary medical histories, which
are part of an employee health program available to employees at that worksite.
WHAT ARE THE REMEDIES AVAILABLE UNDER THE FAIR EMPLOYMENT AND
HOUSING ACT?
Under the Fair Employment and Housing Act, if an employer fails to reasonably
accommodate an applicant or employee, the Fair Employment and Housing
Commission can order the employer to cease and desist the discriminatory practice; to
hire or reinstate; and award actual damages including, but not limited to, lost wages;
emotional distress damages; and administrative fines not to exceed $150,000.00. If the
matter is heard in civil court, the damages would be unlimited.

IF DISCRIMINATION HAS OCCURRED, WHAT CAN BE DONE?
If an applicant or employee believes they have been discriminated against or denied
reasonable accommodation for their disability, they should first try to work with the
immediate supervisor to resolve the issue. If there is still no resolution, they should
contact the employer's reasonable accommodation coordinator, a human resource
representative or the person in charge of accommodation issues. Again, both the
applicant or employee and the employer must engage in a good-faith interactive
process to determine an appropriate resolution.
If the issue is still not resolved, the applicant or employee can contact the Department of
Fair Employment and Housing at any time during the process and file a complaint.
However, they have only one year from the date of harm (denial of accommodation,
discharge, etc.) to file a complaint with the Department.
CONCLUSION
Accommodation of persons with disabilities on the job is important to the maintenance
of good employer/employee relations. Understanding the duties and responsibilities of
employers and supervisors to provide accessible workplaces is critical to ensuring that
physical or mental limitations are not insurmountable barriers to those wiling to work.
If you require further information,
please contact the department toll free at:
(800) 884-1684 For Employment
(800) 233-3212 For Housing
TTY (800) 700-2320
Or
Visit our website at:
ww.dfeh.ca.gov

The U.S. Equal Employment Opportunity Commission
EEOC I
NOTICE
915.002
INumber ~
IOctober 17, 2002
1. SUBJECT: EEOC Enforcement Guidance on Reasonable Accommodation and Undue
Hardship Under the Americans with Disabilities Act
2. PURPOSE: This enforcement guidance supersedes the enforcement guidance issued by
the Commission on 03/01/99. Most of the original guidance remains the same, but
limited changes have been made as a result of: (1) the Supreme Court's decision in US
Airways, Inc. v. Barnett, 535 U.S., 122 S. Ct. 1516 (2002), and (2) the Commission's
issuance of new regulations under section 501 of the Rehabilitation Act. The major
changes in response to the Barnett decision are found on pages 4-5, 44-45, and 61-62.
In addition, minor changes were made to certain footnotes and the Instructions for
Investigators as a result of the Barnett decision and the new section 501 regulations.
3. EFFECTIVE DATE: Upon receipt.
4. EXPIRATION DATE: As an exception to EEOC Order 205.001, Appendix B,
Attachment 4, . a(5), this Notice will remain in effect until rescinded or
superseded.
5. ORIGINATOR: ADA Division, Office of Legal CounseL.
6. INSTRUCTIONS: File after Section 902 of Volume II of the Compliance ManuaL.
Enforcement Guidance:
Reasonable Accommodation and Undue
Hardship Under the Americans with
Disabilities Act
INTRODUCTION
GENERAL PRINCIPLES
Table of Contents
REOUESTING REASONABLE ACCOMMODATION
REASONABLE ACCOMMODATION AND JOB APPLICANTS

REASONABLE ACCOMMODATION RELATED TO THE BENEFITS AND.PRIVILEGES OF
EMPLOYMENT
TYPES OF REASONABLE ACCOMMODATIONS RELATED TO JOB PERFORMANCE
JOB RESTRUCTURING
LEAVE
MODIFIED OR PART-TIME SCHEDULE
MODIFIED WORKPLACE POLICIES
REASSIGNMENT
OTHER REASONABLE ACCOMMODATION ISSUES
UNDUE HARDSHIP ISSUES
BURDENS OF PROOF
INSTRUCTIONS FOR INVESTIGATORS
APPENDIX: RESOURCES FOR LOCATING REASONABLE ACCOMMODATIONS
INDEX
Enforcement Guidance:
Reasonable Accommodation and Undue
Hardship Under the Americans with
Disabilities Act
INTRODUCTION
This Enforcement Guidance clarifies the rights and responsibilities of employers and
individuals with disabilities regarding reasonable accommodation and undue hardship.
Title I of the ADA requires an employer to provide reasonable accommodation to qualified
individuals with disabilities who are employees or applicants for employment, except
when such accommodation would cause an undue hardship. This Guidance sets forth an
employer's legal obligations regarding reasonable accommodation; however, employers
may provide more than the law requires.

This Guidance examines what "reasonable accommodation" means and who is entitled to
receive it. The Guidance addresses what constitutes a request for reasonable
accommodation, the form and substance of the request, and an employer's ability to ask
questions and seek documentation after a request has been made.
The Guidance discusses reasonable accommodations applicable to the hiring process and
to the benefits and privileges of employment. The Guidance also covers different types of
reasonable accommodations related to job performance, including job restructuring,
leave, modified or part-time schedules, modified workplace policies, and reassignment.
Questions concerning the relationship between the ADA and the Family and Medical Leave
Act (FMLA) are examined as they affect leave and modified schedules. Reassignment
issues addressed include who is entitled to reassignment and the extent to which an
employer must search for a vacant position. The Guidance also examines issues
concerning the interplay between reasonable accommodations and conduct rules.
The final section of this Guidance discusses undue hardship, including when requests for
schedule modifications and leave may be denied.
Reasonable Accommodation
GENERAL PRINCIPLES
Title I of the Americans with Disabilities Act of 1990 (the "ADA")il requires an
employerW to provide reasonable accommodation to qualified individuals with disabilities
who are employees or applicants for employment, unless to do so would cause undue
hardship. "In general, an accommodation is any change in the work environment or in
the way things are customarily done that enables an individual with a disability to enjoy
equal employment opportunities."UlThere are three categories of "reasonable
accommodations" :
"(i) modifications or adjustments to a job application process that enable a qualified
applicant with a disability to be considered for the position such qualified applicant
desires; or
(ii) modifications or adjustments to the work environment, or to the manner or
circumstances under which the position held or desired is customarily performed, that
enable a qualified individual with a disability to perform the essential functions of that
position; or
(iii) modifications or adjustments that enable a covered entity's employee with a
disability to enjoy equal benefits and privileges of employment as are enjoyed by its
other similarly situated employees without disabilities."il
The duty to provide reasonable accommodation is a fundamental statutory requirement
because of the nature of discrimination faced by individuals with disabilities. Although
many individuals with disabilities can apply for and perform jobs without any reasonable
accommodations, there are workplace barriers that keep others from performing jobs
which they could do with some form of accommodation. These barriers may be physical
obstacles (such as inaccessible facilities or equipment), or they may be procedures or
rules (such as rules concerning when work is performed, when breaks are taken, or how
essential or marginal functions are performed). Reasonable accommodation removes
workplace barriers for individuals with disabilities.

Reasonable accommodation is available to qualified applicants and employees with
disabilities.il Reasonable accommodations must be provided to qualified employees
regardless of whether they work part- time or full-time, or are considered "probationary,"
Generally, the individual with a disability must inform the employer that an
accommodation is needed.æ
There are a number of possible reasonable accommodations that an employer may have
to provide in connection with modifications to the work environment or adjustments in
how and when a job is performed. These include:
making existing facilities accessible;
job restructuring;
part-time or modified work schedules;
acquiring or modifying equipment;
changing tests, training materials, or policies;
providing qualified readers or interpreters; and
reassignment to a vacant position.il
A modification or adjustment is "reasonable" if it "seems reasonable on its face, i.e.,
ordinarily or in the run of cases; "m this means it is "reasonable" if it appears to be
"feasible" or "plausible."ffAn accommodation also must be effective in meeting the needs
of the individual.il In the context of job performance, this means that a reasonable
accommodation enables the individual to perform the essential functions of the position.
Similarly, a reasonable accommodation enables an applicant with a disability to have an
equal opportunity to participate in the application process and to be considered for a job.
Finally, a reasonable accommodation allows an employee with a disability an equal
opportunity to enjoy the benefits and privileges of employment that employees without
disabilities enjoy.
ExamDle A: An employee with a hearing disability must be able to contact the public by
telephone. The employee proposes that he use a TTil to call a relay service operator
who can then place the telephone call and relay the conversation between the parties.
This is "reasonable" because a TT is a common device used to facilitate communication
between hearing and hearing-impaired individuals. Moreover, it would be effective in
enabling the employee to perform his job.
ExamDle B: A cashier easily becomes fatigued because of lupus and, as a result, has
difficulty making it through her shift. The employee requests a stool because sitting
greatly reduces the fatigue. This accommodation is reasonable because it is a commonsense
solution to remove a workplace barrier being required to stand when the job can
be effectively performed sitting down. This "reasonable" accommodation is effective
because it addresses the employee's fatigue and enables her to perform her job.
ExamDle C: A cleaning company rotates its staff to different floors on a monthly basis.
One crew member has a psychiatric disability. While his mental illness does not affect his
ability to perform the various cleaning functions, it does make it difficult to adjust to
alterations in his daily routine. The employee has had significant difficulty adjusting to
the monthly changes in floor assignments. He asks for a reasonable accommodation and
proposes three options: staying on one floor permanently, staying on one floor for two
months and then rotating, or allowing a transition period to adjust to a change in floor

assignments. These accommodations are reasonable because they appear to be feasible
solutions to this employee's problems dealing with changes to his routine. They also
appear to be effective because they would enable him to perform his cleaning duties.
There are several modifications or adjustments that are not considered forms of
reasonable accommodation.il An employer does not have to eliminate an essential
function, i.e., a fundamental duty of the position. This is because a person with a
disability who is unable to perform the essential functions, with or without reasonable
accommodation,il is not a "qualified" individual with a disability within the meaning of
the ADA. Nor is an employer required to lower production standards n whether
qualitative or quantitative.l n that are applied uniformly to employees with an,d without
disabilities. However, an employer may have to provide reasonable accommodation to
enable an employee with a disability to meet the production standard. While an employer
is not required to eliminate an essential function or lower a production standard, it may
do so if it wishes.
An employer does not have to provide as reasonable accommodations personal use items
needed in accomplishing daily activities both on and off the job. Thus, an employer is not
required to provide an employee with a prosthetic limb, a wheelchair, eyeglasses, hearing
aids, or similar devices if they are also needed off the job. Furthermore, an employer is
not required to provide personal use amenities, such as a hot pot or refrigerator, if those
items are not provided to employees without disabilities. However, items that might
otherwise be considered personal may be required as reasonable accommodations where
they are specifically designed or required to meet job-related rather than personal
needs...
Undue HardshiD
The only statutory limitation on an employer's obligation to provide "reasonable
accommodation" is that no such change or modification is required if it would cause
"undue hardship" to the employer.il"Undue hardship" means significant difficulty or
expense and focuses on the resources and circumstances of the particular employer in
relationship to the cost or difficulty of providing a specific accommodation. Undue
hardship refers not only to financial difficulty, but to reasonable accommodations that are
unduly extensive, substantial, or disruptive, or those that would fundamentally alter the
nature or operation of the business.il An employer must assess on a case-by-case basis
whether a particular reasonable accommodation would cause undue hardship. The ADA's
"undue hardship" standard is different from that applied by courts under Title VII of the
Civil Rights Act of 1964 for religious accommodation.UI
REQUESTING REASONABLE ACCOMMODATION
1. How must an individual request a reasonable accommodation?
When an individual decides to request accommodation, the individual or his/her
representative must let the employer know that s/he needs an adjustment or
change at work for a reason related to a medical condition. To request
accommodation, an individual may use "plain English" and need not mention the
ADA or use the phrase "reasonable accommodation."il
ExamDle A: An employee tells her supervisor, "I'm having trouble getting to work
at my scheduled starting time because of medical treatments I'm undergoing."
This is a request for a reasonable accommodation.

ExamDle B: An employee tells his supervisor, "I need six weeks off to get
treatment for a back problem." This is a request for a reasonable accommodation,
ExamDle C: A new employee, who uses a wheelchair, informs the employer that
her wheelchair cannot fit under the desk in her office. This is a request for
reasonable accommodation.
ExamDle D: An employee tells his supervisor that he would like a new chair
because his present one is uncomfortable. Although this is a request for a change
at work, his statement is insufficient to put the employer on notice that he is
requesting reasonable accommodation. He does not link his need for the new
chair with a medical condition.
While an individual with a disability may request a change due to a medical
condition, this request does not necessarily mean that the employer is required to
provide the change. A request for reasonable accommodation is the first step in
an informal, interactive process between the individual and the employer. In some
instances, before addressing the merits of the accommodation request, the
employer needs to determine if the individual's medical condition meets the ADA
definition of "disability,"ß. a prerequisite for the individual to be entitled to a
reasonable accommodation.
2. May someone other than the individual with a disability request a reasonable
accommodation on behalf of the individual?
Yes, a family member, friend, health professional, or other representative may
request a reasonable accommodation on behalf of an individual with a
disability.LW Of course, the individual with a disability may refuse to accept an
accommodation that is not needed.
ExamDle A: An employee's spouse phones the employee's supervisor on Monday
morning to inform her that the employee had a medical emergency due to
multiple sclerosis, needed to be hospitalized, and thus requires time off. This
discussion constitutes a request for reasonable accommodation.
ExamDle B: An employee has been out of work for six months with a workers'
compensation injury. The employee's doctor sends the employer a letter, stating
that the employee is released to return to work, but with certain work restrictions.
(Alternatively, the letter may state that the employee is released to return to a
light duty position.) The letter constitutes a request for reasonable
accommodation.
3. Do requests for reasonable accommodation need to be in writing?
No. Requests for reasonable accommodation do not need to be in writing.
Individuals may request accommodations in conversation or may use any other
mode of communication.ílAn employer may choose to write a memorandum or
letter confirming the individual's request. Alternatively, an employer may ask the
individual to fill out a form or submit the request in written form, but the
employer cannot ignore the initial request. An employer also may request
reasonable documentation that the individual has an ADA disability and needs a
reasonable accommodation, (See Question 6).

4. When should an individual with a disability request a reasonable accommodation?
An individual with a disability may request a reasonable accommodation at any
time during the application process or during the period of employment. The ADA
does not preclude an employee with a disability from requesting a reasonable
accommodation because s/he did not ask for one when applying for a job or after
receiving a job offer. Rather, an individual with a disability should request a
reasonable accommodation when s/he knows that there is a workplace barrier
that is preventing him/her, due to a disability, from effectively competing for a
position, performing a job, or gaining equal access to a benefit of employment,ín
As a practical matter, it may be in an employee's interest to request a reasonable
accommodation before performance suffers or conduct problems occur.
5. What must an employer do after receiving a request for reasonable
accommodation?
The employer and the individual with a disability should engage in an informal
process to clarify what the individual needs and identify the appropriate
reasonable accommodation.il The employer may ask the individual relevant
questions that will enable it to make an informed decision about the request. This
includes asking what type of reasonable accommodation is needed.Lm
The exact nature of the dialogue will vary. In many instances, both the disability
and the type of accommodation required will be obvious, and thus there may be
little or no need to engage in any discussion. In other situations, the employer
may need to ask questions concerning the nature of the disability and the
individual's functional limitations in order to identify an effective accommodation.
While the individual with a disability does not have to be able to specify the
precise accommodation, s/he does need to describe the problems posed by the
workplace barrier. Additionally, suggestions from the individual with a disability
may assist the employer in determining the type of reasonable accommodation to
provide. Where the individual or the employer are not familiar with possible
accommodations, there are extensive public and private resources to help the
employer identify reasonable accommodations once the specific limitations and
workplace barriers have been ascertained.U2
6. Mayan employer ask an individual for documentation when the individual
requests reasonable accommodation?
Yes. When the disability and/or the need for accommodation is not obvious, the
employer may ask the individual for reasonable documentation about his/her
disability and functional limitations. il The employer is entitled to know that the
individual has a covered disability for which s/he needs a reasonable
accommodation.
Reasonable documentation means that the employer may require only the
documentation that is needed to establish that a person has an ADA disability,
and that the disability necessitates a reasonable accommodation. Thus, an
employer, in response to a request for reasonable accommodation, cannot ask for
documentation that is unrelated to determining the existence of a disability and
the necessity for an accommodation. This means that in most situations an
employer cannot request a person's complete medical records because they are
likely to contain information unrelated to the disability at issue and the need for
accommodation. If an individual has more than one disability, an employer can

equest information pertaining only to the disability that requires a reasonable
accommodation.
An employer may require that the documentation about the disability and the
functional limitations come from an appropriate health care or rehabilitation
professionaL. The appropriate professional in any particular situation will depend
on the disability and the type of functional limitation it imposes. Appropriate
professionals include, but are not limited to, doctors (including psychiatrists),
psychologists, nurses, physical therapists, occupational therapists, speech
therapists, vocational rehabilitation specialists, and licensed mental health
professionals.
In requesting documentation, employers should specify what types of information
they are seeking regarding the disability, its functional limitations, and the need
for reasonable accommodation. The individual can be asked to sign a limited
release allowing the employer to submit a list of specific questions to the health
care or vocational professional.WU
As an alternative to requesting documentation, an employer may simply discuss
with the person the nature of his/her disability and functional limitations. It would
be useful for the employer to make clear to the individual why it is requesting
information, i.e., to verify the existence of an ADA disability and the need for a
reasonable accommodation.
ExamDle A: An employee says to an employer, "I'm having trouble reaching tools
because of my shoulder injury." The employer may ask the employee for
documentation describing the impairment; the nature, severity, and duration of
the impairment; the activity or activities that the impairment limits; and the
extent to which the impairment limits the employee's ability to perform the
activity or activities (i.e., the employer is seeking information as to whether the
employee has an ADA disability).
ExamDle B: A marketing employee has a severe learning disability. He attends
numerous meetings to plan marketing strategies. In order to remember what is
discussed at these meetings he must take detailed notes but, due to his disability,
he has great difficulty writing. The employee tells his supervisor about his
disability and requests a laptop computer to use in the meetings. Since neither
the disability nor the need for accommodation are obvious, the supervisor may
ask the employee for reasonable documentation about his impairment; the
nature, severity, and duration of the impairment; the activity or activities that the
impairment limits; and the extent to which the impairment limits the employee's
ability to perform the activity or activities. The employer also may ask why the
disability necessitates use of a laptop computer (or any other type of reasonable
accommodation, such as a tape recorder) to help the employee retain the
information from the meetings.U2
ExamDle C: An employee's spouse phones the employee's supervisor on Monday
morning to inform her that the employee had a medical emergency due to
multiple sclerosis, needed to be hospitalized, and thus requires time off. The
supervisor can ask the spouse to send in documentation from the employee's
treating physician that confirms that the hospitalization was related to the
multiple sclerosis and provides information on how long an absence may be
required from work.ll

If an individual's disability or need for reasonable accommodation is not obvious,
and s/he refuses to provide the reasonable documentation requested by the
employer, then s/he is not entitled to reasonable accommodation.ll On the other
hand, failure by the employer to initiate or participate in an informal dialogue with
the individual after receiving a request for reasonable accommodation could result
in liability for failure to provide a reasonable accommodation.Lm
7. Mayan employer require an individual to go to a health care professional of the
employer's (rather than the employee's) choice for purposes of documenting need
for accommodation and disability?
The ADA does not prevent an employer from requiring an individual to go to an
appropriate health professional of the employer's choice if the individual provides
insufficient information from his/her treating physician (or other health care
professional) to substantiate that s/he has an ADA disability and needs a
reasonable accommodation. However, if an individual provides insufficient
documentation in response to the employer's initial request, the employer should
explain why the documentation is insufficient and allow the individual an
opportunity to provide the missing information in a timely manner.
Documentation is insufficient if it does not specify the existence of an ADA
disability and explain the need for reasonable accommodation..m
Any medical examination conducted by the employer's health professional must
be job-related and consistent with business necessity. This means that the
examination must be limited to determining the existence of an ADA disability and
the functional limitations that require reasonable accommodation.llIf an
employer requires an employee to go to a health professional of the employer's
choice, the employer must pay all costs associated with the visit(s).
8. Are there situations in which an employer cannot ask for documentation in
response to a request for reasonable accommodation?
Yes. An employer cannot ask for documentation when: (1) both the disability and
the need for reasonable accommodation are obvious, or (2) the individual has
already provided the employer with sufficient information to substantiate that
s/he has an ADA disability and needs the reasonable accommodation requested.
ExamDle A: An employee brings a note from her treating physician explaining that
she has diabetes and that, as a result, she must test her blood sugar several
times a day to ensure that her insulin level is safe in order to avoid a
hyperglycemic reaction. The note explains that a hyperglycemic reaction can
include extreme thirst, heavy breathing, drowsiness, and flushed skin, and
eventually would result in unconsciousness. Depending on the results of the blood
test, the employee might have to take insulin. The note requests that the
employee be allowed three or four 10-minute breaks each day to test her blood,
and if necessary, to take insulin. The doctor's note constitutes sufficient
documentation that the person has an ADA disability because it describes a
substantially limiting impairment and the reasonable accommodation needed as a
result. The employer cannot ask for additional documentation.
ExamDle B: One year ago, an employer learned that an employee had bipolar
disorder after he requested a reasonable accommodation. The documentation
provided at that time from the employee's psychiatrist indicated that this was a
permanent condition which would always involve periods in which the disability

would remit and then intensify. The psychiatrist's letter explained that during
periods when the condition flared up, the person's manic moods or depressive
episodes could be severe enough to create serious problems for the individual in
caring for himself or working, and that medication controlled the frequency and
severity of these episodes.
Now, one year later, the employee again requests a reasonable accommodation
related to his bipolar disorder. Under these facts, the employer may ask for
reasonable documentation on the need for the accommodation (if the need is not
obvious), but it cannot ask for documentation that the person has an ADA
disability. The medical information provided one year ago established the
existence of a long-term impairment that substantially limits a major life activity.
ExamDle C: An employee gives her employer a letter from her doctor, stating that
the employee has asthma and needs the employer to provide her with an air
filter. This letter contains insufficient information as to whether the asthma is an
ADA disability because it does not provide any information as to its severity (i.e.,
whether it substantially limits a major life activity). Furthermore, the letter does
not identify precisely what problem exists in the workplace that requires an air
filter or any other reasonable accommodation. Therefore, the employer can
request additional documentation.
9. Is an employer required to provide the reasonable accommodation that the
individual wants?
The employer may choose among reasonable accommodations as long as the
chosen accommodation is effective.Lr Thus, as part of the interactive process,
the employer may offer alternative suggestions for reasonable accommodations
and discuss their effectiveness in removing the workplace barrier that is impeding
the individual with a disability.
If there are two possible reasonable accommodations, and one costs more or is
more burdensome than the other, the employer may choose the less expensive or
burdensome accommodation as long as it is effective (i.e., it would remove a
workplace barrier, thereby providing the individual with an equal opportunity to
apply for a position, to perform the essential functions of a position, or to gain
equal access to a benefit or privilege of employment). Similarly, when there are
two or more effective accommodations, the employer may choose the one that is
easier to provide. In either situation, the employer does not have to show that it
is an undue hardship to provide the more expensive or more difficult
accommodation. If more than one accommodation is effective, "the preference of
the individual with a disability should be given primary consideration. However,
the employer providing the accommodation has the ultimate discretion to choose
between effective accommodations."QQ
ExamDle A: An employee with a severe learning disability has great difficulty
reading. His supervisor sends him many detailed memoranda which he often has
trouble understanding. However, he has no difficulty understanding oral
communication. The employee requests that the employer install a computer with
speech output and that his supervisor send all memoranda through electronic mail
which the computer can then read to him. The supervisor asks whether a tape
recorded message would accomplish the same objective and the employee agrees
that it would. Since both accommodations are effective, the employer may choose

to provide the supervisor and employee with a tape recorder so that the
supervisor can record her memoranda and the employee can listen to them.
ExamDle B: An attorney with a severe vision disability requests that her employer
provide someone to read printed materials that she needs to review daily, The
attorney explains that a reader enables her to review substantial amounts of
written materials in an efficient manner. Believing that this reasonable
accommodation would be too costly, the employer instead provides the attorney
with a device that allows her to magnify print so that she can read it herself. The
attorney can read print using this device, but with such great difficulty it
significantly slows down her ability to review written materials. The magnifying
device is ineffective as a reasonable accommodation because it does not provide
the attorney with an equal opportunity to attain the same level of performance as
her colleagues. Without an equal opportunity to attain the same level of
performance, this attorney is denied an equal opportunity to compete for
promotions. In this instance, failure to provide the reader, absent undue hardship,
would violate the ADA.
10. How quickly must an employer respond to a request for reasonable
accommodation?
An employer should respond expeditiously to a request for reasonable
accommodation. If the employer and the individual with a disability need to
engage in an interactive process, this too should proceed as quickly as
possible.Li Similarly, the employer should act promptly to provide the reasonable
accommodation. Unnecessary delays can result in a violation of the ADA.QI
ExamDle A: An employer provides parking for all employees. An employee who
uses a wheelchair requests from his supervisor an accessible parking space,
explaining that the spaces are so narrow that there is insufficient room for his van
to extend the ramp that allows him to get in and out. The supervisor does not act
on the request and does not forward it to someone with authority to respond. The
employee makes a second request to the supervisor. Yet, two months after the
initial request, nothing has been done. Although the supervisor never definitively
denies the request, the lack of action under these circumstances amounts to a
denial, and thus violates the ADA.
ExamDle B: An employee who is blind requests adaptive equipment for her
computer as a reasonable accommodation. The employer must order this
equipment and is informed that it will take three months to receive delivery. No
other company sells the adaptive equipment the employee needs, The employer
notifies the employee of the results of its investigation and that it has ordered the
equipment. Although it will take three months to receive the equipment, the
employer has moved as quickly as it can to obtain it and thus there is no ADA
violation resulting from the delay. The employer and employee should determine
what can be done so that the employee can perform his/her job as effectively as
possible while waiting for the equipment.
11. Mayan employer require an individual with a disability to accept a reasonable
accommodation that s/he does not want?
No. An employer may not require a qualified individual with a disability to accept
an accommodation. If, however, an employee needs a reasonable accommodation
to perform an essential function or to eliminate a direct threat, and refuses to

accept an effective accommodation, s/he may not be qualified to remain in the
job.ll
REASONABLE ACCOMMODATION AND JOB
APPLICANTS
12. Mayan employer ask whether a reasonable accommodation is needed when an
applicant has not asked for one?
An employer may tell applicants what the hiring process involves (e.g., an
interview, timed written test, or job demonstration), and may ask applicants
whether they will need a reasonable accommodation for this process.
During the hiring process and before a conditional offer is made, an employer
generally may not ask an applicant whether s/he needs a reasonable
accommodation for the job, except when the employer knows that an applicant
has a disability n either because it is obvious or the applicant has voluntarily
disclosed the information -- and could reasonably believe that the applicant will
need a reasonable accommodation to perform specific job functions. If the
applicant replies that s/he needs a reasonable accommodation, the employer may
inquire as to what type. .w
After a conditional offer of employment is extended, an employer may inquire
whether applicants will need reasonable accommodations related to anything
connected with the job (i.e., job performance or access to benefits/privileges of
the job) as long as all entering employees in the same job category are asked this
question. Alternatively, an employer may ask a specific applicant if s/he needs a
reasonable accommodation if the employer knows that this applicant has a
disability n either because it is obvious or the applicant has voluntarily disclosed
the information n and could reasonably believe that the applicant will need a
reasonable accommodation. If the applicant replies that s/he needs a reasonable
accommodation, the employer may inquire as to what type.il
13. Does an employer have to provide a reasonable accommodation to an applicant
with a disability even if it believes that it will be unable to provide this individual
with a reasonable accommodation on the job?
Yes. An employer must provide a reasonable accommodation to a qualified
applicant with a disability that will enable the individual to have an equal
opportunity to participate in the application process and to be considered for a job
(unless it can show undue hardship). Thus, individuals with disabilities who meet
initial requirements to be considered for a job should not be excluded from the
application process because the employer speculates, based on a request for
reasonable accommodation for the application process, that it will be unable to
provide the individual with reasonable accommodation to perform the job. In
many instances, employers will be unable to determine whether an individual
needs reasonable accommodation to perform a job based solely on a request for
accommodation during the application process. And even if an individual will need
reasonable accommodation to perform the job, it may not be the same type or
degree of accommodation that is needed for the application process. Thus, an
employer should assess the need for accommodations for the application process
separately from those that may be needed to perform the job. Hl

ExamDle A: An employer is impressed with an applicant's resume and contacts
the individual to come in for an interview. The applicant, who is deaf, requests a
sign language interpreter for the interview. The employer cancels the interview
and refuses to consider further this applicant because it believes it would have to
hire a full-time interpreter. The employer has violated the ADA. The employer
should have proceeded with the interview, using a sign language interpreter
(absent undue hardship), and at the interview inquired to what extent the
individual would need a sign language interpreter to perform any essential
functions requiring communication with other people.
ExamDle B: An individual who has paraplegia applies for a secretarial position.
Because the office has two steps at the entrance, the employer arranges for the
applicant to take a typing test, a requirement of the application process, at a
different location. The applicant fails the test. The employer does not have to
provide any further reasonable accommodations for this individual because she is
no longer qualified to continue with the application process.
REASONABLE ACCOMMODATION RELATED
TO THE BENEFITS AND PRIVILEGES OF
EMPLOYMENT ~
The ADA requires employers to provide reasonable accommodations so that
employees with disabilities can enjoy the "benefits and privileges of employment"
equal to those enjoyed by similarly-situated employees without disabilities.
Benefits and privileges of employment include, but are not limited to, employersponsored:
(1) training, (2) services (e.g., employee assistance programs
(EAP's), credit unions, cafeterias, lounges, gymnasiums, auditoriums,
transportation), and (3) parties or other social functions (e.g., parties to celebrate
retirements and birthdays, and company outings).ilIf an employee with a
disability needs a reasonable accommodation in order to gain access to, and have
an equal opportunity to participate in, these benefits and privileges, then the
employer must provide the accommodation unless it can show undue hardship.
14. Does an employer have to provide reasonable accommodation to enable an
employee with a disability to have equal access to information communicated in
the workplace to non-disabled employees?
Yes. Employers provide information to employees through different means,
including computers, bulletin boards, mailboxes, posters, and public address
systems. Employers must ensure that employees with disabilities have access to
information that is provided to other similarly-situated employees without
disabilities, regardless of whether they need it to perform their jobs.
ExamDle A: An employee who is blind has adaptive equipment for his computer
that integrates him into the network with other employees, thus allowing
communication via electronic mail and access to the computer bulletin board.
When the employer installs upgraded computer equipment, it must provide new
adaptive equipment in order for the employee to be integrated into the new
networks, absent undue hardship. Alternative methods of communication (e.g.,
sending written or telephone messages to the employee instead of electronic
mail) are likely to be ineffective substitutes since electronic mail is used by every
employee and there is no effective way to ensure that each one will always use

alternative measures to ensure that the blind employee receives the same
information that is being transmitted via computer.
ExamDle B: An employer authorizes the Human Resources Director to use a public
address system to remind employees about special meetings and to make certain
announcements. In order to make this information accessible to a deaf employee,
the Human Resources Director arranges to send in advance an electronic mail
message to the deaf employee conveying the information that will be broadcast.
The Human Resources Director is the only person who uses the public address
system; therefore, the employer can ensure that all public address messages are
sent, via electronic mail, to the deaf employee. Thus, the employer is providing
this employee with equal access to office communications.
15. Must an employer provide reasonable accommodation so that an employee may
attend training programs?
Yes. Employers must provide reasonable accommodation (e.g., sign language
interpreters; written materials produced in alternative formats, such as braille,
large print, or on audio- cassette) that will provide employees with disabilities
with an equal opportunity to participate in employer-sponsored training, absent
undue hardship. This obligation extends to in-house training, as well as to training
provided by an outside entity. Similarly, the employer has an obligation to provide
reasonable accommodation whether the training occurs on the employer's
premises or elsewhere.
ExamDle A: XYZ Corp. has signed a contract with Super Trainers, Inc., to provide
mediation training at its facility to all of XYZ's Human Resources staff. One staff
member is blind and requests that materials be provided in braille. Super Trainers
refuses to provide the materials in braille. XYZ maintains that it is the
responsibility of Super Trainers and sees no reason why it should have to arrange
and pay for the braille copy.
Both XYZ (as an employer covered under Title I of the ADA) and Super Trainers
(as a public accommodation covered under Title III of the ADA).c have
obligations to provide materials in alternative formats. This fact, however, does
not excuse either one from their respective obligations. If Super Trainers refuses
to provide the braille version, despite its Title III obligations, XYZ still retains its
obligation to provide it as a reasonable accommodation, absent undue hardship.
Employers arranging with an outside entity to provide training may wish to avoid
such problems by specifying in the contract who has the responsibility to provide
appropriate reasonable accommodations. Similarly, employers should ensure that
any offsite training will be held in an accessible facility if they have an employee
who, because of a disability, requires such an accommodation.
ExamDle B: XYZ Corp. arranges for one of its employees to provide CPR training.
This three-hour program is optionaL. A deaf employee wishes to take the training
and requests a sign language interpreter. XYZ must provide the interpreter
because the CPR training is a benefit that XYZ offers all employees, even though
it is optionaL.

TYPES OF REASONABLE
ACCOMMODATIONS RELATED TO JOB
PERFORMANCEil
Below are discussed certain types of reasonable accommodations related to job
performance.
Job Restructurina
Job restructuring includes modifications such as:
o reallocating or redistributing marginal job functions that an employee is
unable to perform because of a disability; and
o
altering when and/or how a function, essential or marginal, is
performed. in
An employer never has to reallocate essential functions as a reasonable
accommodation, but can do so if it wishes.
16. If, as a reasonable accommodation, an employer restructures an employee's job
to eliminate some marginal functions, may the employer require the employee to
take on other marginal functions that s/he can perform?
Yes. An employer may switch the marginal functions of two (or more) employees
in order to restructure a job as a reasonable accommodation.
ExamDle: A cleaning crew works in an office building. One member of the crew
wears a prosthetic leg which enables him to walk very well, but climbing steps is
painful and difficult. Although he can perform his essential functions without
problems, he cannot perform the marginal function of sweeping the steps located
throughout the building. The marginal functions of a second crew member include
cleaning the small kitchen in the employee's lounge, which is something the first
crew member can perform. The employer can switch the marginal functions
performed by these two employees.
Leave
Permitting the use of accrued paid leave, or unpaid leave, is a form of reasonable
accommodation when necessitated by an employee's disability.í1 An employer
does not have to provide paid leave beyond that which is provided to similarlysituated
employees. Employers should allow an employee with a disability to
exhaust accrued paid leave first and then provide unpaid leave.L1 For example, if
employees get 10 days of paid leave, and an employee with a disability needs 15
days of leave, the employer should allow the individual to use 10 days of paid
leave and 5 days of unpaid leave.
An employee with a disability may need leave for a number of reasons related to
the disability, including, but not limited to:

o obtaining medical treatment (e.g., surgery, psychotherapy, substance
abuse treatment, or dialysis); rehabilitation services; or physical or
occupational therapy;
o
o
o
recuperating from an illness or an episodic manifestation of the disability;
obtaining repairs on a wheelchair, accessible van, or prosthetic device;
avoiding temporary adverse conditions in the work environment (for
example, an air-conditioning breakdown causing unusually warm
temperatures that could seriously harm an employee with multiple
sclerosis) ;
o training a service animal (e.g., a guide dog); or
o
receiving training in the use of braille or to learn sign language.
17. Mayan employer apply a "no-fault" leave policy, under which employees are
automatically terminated after they have been on leave for a certain period of
time, to an employee with a disability who needs leave beyond the set period?
No. If an employee with a disability needs additional unpaid leave as a reasonable
accommodation, the employer must modify its "no-fault" leave policy to provide
the employee with the additional leave, unless it can show that: (1) there is
another effective accommodation that would enable the person to perform the
essential functions of his/her position, or (2) granting additional leave would
cause an undue hardship. Modifying workplace policies, including leave policies, is
a form of reasonable accommodation.fi
18. Does an employer have to hold open an employee's job as a reasonable
accommodation?
Yes. An employee with a disability who is granted leave as a reasonable
accommodation is entitled to return to his/her same position unless the employer
demonstrates that holding open the position would impose an undue hardship.Li
If an employer cannot hold a position open during the entire leave period without
incurring undue hardship, the employer must consider whether it has a vacant,
equivalent position for which the employee is qualified and to which the employee
can be reassigned to continue his/her leave for a specific period of time and then,
at the conclusion of the leave, can be returned to this new position.Li
ExamDle: An employee needs eight months of leave for treatment and
recuperation related to a disability. The employer grants the request, but after
four months the employer determines that it can no lònger hold open the position
for the remaining four months without incurring undue hardship. The employer
must consider whether it has a vacant, equivalent position to which the employee
can be reassigned for the remaining four months of leave, at the end of which
time the employee would return to work in that new position. If an equivalent
position is not available, the employer must look for a vacant position at a lower
leveL. Continued leave is not required as a reasonable accommodation if a vacant
position at a lower level is also unavailable.
19. Can an employer penalize an employee for work missed during leave taken as a
reasonable accommodation?

Bultemeyer v. Ft. Wayne Community Schs., 100 F.3d 1281, 1285, 6 AD Cas. (BNA) 67, 71 (7th
Cir. 1996) (an employee with a known psychiatric disability requested reasonable
accommodation by stating that he could not do a particular job and by submitting a note from
his psychiatrist); McGinnis v. Wonder Chemical Co., 5 AD Cas. (BNA) 219 (E.D. Pa. 1995)
(employer on notice that accommodation had been requested because: (1) employee told
supervisor that his pain prevented him from working and (2) employee had requested leave
under the Family and Medical Leave Act).
Nothing in the ADA requires an individual to use legal terms or to anticipate all of the possible
information an employer may need in order to provide a reasonable accommodation. The ADA
avoids a formulistic approach in favor of an interactive discussion between the employer and the
individual with a disability, after the individual has requested a change due to a medical
condition. Nevertheless, some courts have required that individuals initially provide detailed
information in order to trigger the employer's duty to investigate whether reasonable
accommodation is required. See, e.g., Taylor v, Principal Fin. Group, Inc., 93 F.3d 155, 165, 5
AD Cas. (BNA) 1653, 1660 (5th Cir. 1996); Miller v. Nat'l Cas. Co., 61 F.3d 627, 629-30, 4 AD
Cas. (BNA) 1089, 1090-91 (8th Cir. 1995).
20. See Questions 5 - 7, infra, for a further discussion on when an employer may request
reasonable documentation about a person's "disability" and the need for reasonable
accommodation.
21. Cf. Beck v. Univ. of Wis. Bd. of Regents, 75 F.3d 1130, 5 AD Cas. (BNA) 304 (7th Cir. 1996);
Schmidt v. Safeway Inc., 864 F. Supp. 991,997, 3 AD Cas. (BNA) 1141, 1146 (D. Or. 1994). But
see Miller v. Nat" Casualty Co., 61 F.3d 627, 630, 4 AD Cas. (BNA) 1089, 1091 (8th Cir. 1995)
(employer had no duty to investigate reasonable accommodation despite the fact that the
employee's sister notified the employer that the employee "was mentally falling apart and the
family was trying to get her into the hospital").
The employer should be receptive to any relevant information or requests it receives from a third
party acting on the individual's behalf because the reasonable accommodation process presumes
open communication in order to help the employer make an informed decision. See 29 C.F.R. §§
1630.2(0), 1630.9 (1997); 29 C.F.R. pt. 1630 app. §§ 1630.2(0), 1630.9 (1997).
22. Although individuals with disabilities are not required to keep records, they may find it useful
to document requests for reasonable accommodation in the event there is a dispute about
whether or when they requested accommodation. Employers, however, must keep all
employment records, including records of requests for reasonable accommodation, for one year
from the making of the record or the personnel action involved, whichever occurs later. If a
charge is filed, records must be preserved until the charge is resolved. 29 C.F.R. § 1602.14
(1997).
23. Cf. Masterson v. Yellow Freight Sys., Inc., Nos. 98-6126, 98-6025, 1998 WL 856143 (10th
Cir. Dec. 11, 1998) (fact that an employee with a disability does not need a reasonable
accommodation all the time does not relieve employer from providing an accommodation for the
period when he does need one).
24. See 29 C.F.R. § 1630.2(0)(3) (1997); 29 C.F.R. pt, 1630 app. §§ 1630.2(0), 1630.9 (1997);
see also Haschmann v. Time Warner Entertainment Co., 151 F.3d 591, 601, 8 AD Cas. (BNA)
692, 700 (7th Cir. 1998); Dalton v. Subaru-Isuzu, 141 F.3d 667, 677, 7 AD Cas. (BNA) 1872,
1880-81 (7th Cir. 1998). The appendix to the regulations at § 1630.9 provides a detailed
discussion of the reasonable accommodation process.

Engaging in an interactive process helps employers to discover and provide reasonable
accommodation. Moreover, in situations where an employer fails to provide a reasonable
accommodation (and undue hardship would not be a valid defense), evidence that the employer
engaged in an interactive process can demonstrate a "good faith" effort which can protect an
employer from having to pay punitive and certain compensatory damages. See 42 U.S.c. §
1981a(a)(3) (1994).
25. The burden-shifting framework outlined by the Supreme Court in US Airways, Inc, v. Barnett,
535 U.s., 122 S. Ct. 1516, 1523 (2002), does not affect the interactive process between an
employer and an individual seeking reasonable accommodation. See pages 61-62, infra, for a
further discussion.
26. See 29 C.F.R. pt. 1630 app. § 1630.9 (1997). The Appendix to this Guidance provides a list
of resources to identify possible accommodations,
27. 29 C.F,R, pt. 1630 app. § 1630.9 (1997); see also EEOC Enforcement Guidance:
Preemployment Disability-Related Questions and Medical Examinations at 6, 8 FEP Manual (BNA)
405:7191, 7193 (1995) (hereinafter Preemployment Questions and Medical Examinations); EEOC
Enforcement Guidance: The Americans with Disabilities Act and Psychiatric Disabilities at 22-23,
8 FEP Manual (BNA) 405:7461, 7472-73 (1997) (hereinafter ADA and Psychiatric Disabilities).
Although the latter Enforcement Guidance focuses on psychiatric disabilities, the legal standard
under which an employer may request documentation applies to disabilities generally.
When an employee seeks leave as a reasonable accommodation, an employer's request for
documentation about disability and the need for leave may overlap with the certification
requirements of the Family and Medical Leave Act (FMLA), 29 C.F.R. §§ 825.305-.306, 825.310-
.311 (1997).
28. Since a doctor cannot disclose information about a patient without his/her permission, an
employer must obtain a release from the individual that will permit his/her doctor to answer
questions. The release should be clear as to what information will be requested. Employers must
maintain the confidentiality of all medical information collected during this process, regardless of
where the information comes from. See Question 42 and note 111, infra.
29. See Question 9, infra, for information on choosing between two or more effective
accommodations.
30. This employee also might be covered under the Family and Medical Leave Act, and if so, the
employer would need to comply with the requirements of that statute.
31. See Templeton v, Neodata Servs., Inc., No, 98-1106, 1998 WL 852516 (10th Cir. Dec. 10,
1998); Beck v. Univ. of Wis. Bd. of Regents, 75 F.3d 1130, 1134, 5 AD Cas. (BNA) 304, 307 (7th
Cir. 1996); McAlpin v. National Semiconductor Corp., 921 F. Supp. 1518, 1525, 5 AD Cas. (BNA)
1047, 1052 (N.D. Tex. 1996).
32. See Hendricks-Robinson v. Excel Corp., 154 F.3d 685, 700, 8 AD Cas. (BNA) 875, 887 (7th
Cir. 1998).
33. If an individual provides sufficient documentation to show the existence of an ADA disability
and the need for reasonable accommodation, continued efforts by the employer to require that
the individual see the employer's health professional could be considered retaliation.

34. Employers also may consider alternatives like having their health professional consult with
the individual's health professional, with the employee's consent.
35. See 29 C.F.R. pt. 1630 app. § 1630.9 (1997); see also Stewart v. Happy Herman's Cheshire
Bridge, Inc., 117 F.3d 1278, 1285-86, 6 AD Cas. (BNA) 1834, 1839 (11th Cir. 1997); Hankins v.
The Gap, Inc., 84 F.3d 797, 800, 5 AD Cas. (BNA) 924, 926-27 (6th Cir. 1996); Gile v, United
Airlines, Inc., 95 F.3d 492, 499, 5 AD Cas. (BNA) 1466, 1471 (7th Cir. 1996).
36. 29 C.F.R. pt. 1630 app. §1630.9 (1997).
37. See Dalton v. Subaru-Isuzu Automotive, Inc., 141 F.3d 667, 677, TAD Cas. (BNA) 1872,
1880 (7th Cir. 1998).
38. In determining whether there has been an unnecessary delay in responding to a request for
reasonable accommodation, relevant factors would include: (1) the reason(s) for the delay, (2)
the length of the delay, (3) how much the individual with a disability and the employer each
contributed to the delay, (4) what the employer was doing during the delay, and (5) whether the
required accommodation was simple or complex to provide.
39. See 29 C.F.R. pt. 1630 app. § 1630.9 (1997); see also Hankins v. The Gap, Inc., 84 F.3d
797, 801, 5 AD Cas. (BNA) 924, 927 (6th Cir. 1996).
40.42 U.S.c. § 12112(d)(2)(A) (1994); 29 C.F.R. § 1630.13(a) (1997). For a thorough
discussion of these requirements, see Preemployment Questions and Medical Examinations,
supra note 27, at 6-8,8 FEP Manual (BNA) 405:7193-94.
41. 42 U.S.c. § 12112(d)(3) (1994); 29 C.F.R. § 1630.14(b) (1997); see also Preemployment
Questions and Medical Examinations, supra note 27, at 20, 8 FEP Manual (BNA) 405:7201.
42. See Question 12, supra, for the circumstances under which an employer may ask an
applicant whether s/he will need reasonable accommodation to perform specific job functions.
43. The discussions and examples in this section assume that there is only one effective
accommodation and that the reasonable accommodation will not cause undue hardship.
44. See 29 C.F.R. pt. 1630 app. § 1630.9 (1997).
45. 42 U.S.c. §§ 12181(7), 12182(1)(A), (2)(A)(iii) (1994).
46. The discussions and examples in this section assume that there is only one effective
accommodation and that the reasonable accommodation will not cause undue hardship.
The types of reasonable accommodations discussed in this section are not exhaustive, For
example, employees with disabilities may request reasonable accommodations to modify the
work environment, such as changes to the ventilation system or relocation of a work space.
See the Appendix for additional resources to identify other possible reasonable accommodations.
47. 42 U.S.c. § 12111(9)(B) (1994); 29 C.F.R. pt. 1630 app. §§ 1630.2(0), 1630.9 (1997); see
Benson v. Northwest Airlines, Inc., 62 F.3d 1108, 1112-13,4 AD Cas. (BNA) 1234, 1236-37 (8th
Cir. 1995).

48. 29 C.F.R. pt. 1630 app. § 1630.2(0) (1997). See Cehrs v. Northeast Ohio Alzheimer's, 155
F.3d 775, 782, 8 AD Cas. (BNA) 825, 830-31 (6th Cir, 1998).
An employee who needs leave, or a part-time or modified schedule, as a reasonable
accommodation also may be entitled to leave under the Family and Medical Leave Act. See
Questions 21 and 23, infra.
49. See A Technical Assistance Manual on the Employment Provisions (Title I) of the Americans
with Disabilities Act, at 3.10(4), 8 FEP Manual (BNA) 405:6981, 7011 (1992) (hereinafter TAM).
50. 42 U.S.c. § 12111(9)(B) (1994); 29 C.F.R. § 1630.2(0)(2)(ii) (1997). See US Airways, Inc.
v. Barnett, 535 U.S., 122 S. Ct. 1516, 1521 (2002). See also Question 24, infra. While undue
hardship cannot be based solely on the existence of a no-fault leave policy, the employer may be
able to show undue hardship based on an individualized assessment showing the disruption to
the employer's operations if additional leave is granted beyond the period allowed by the policy.
In determining whether undue hardship exists, the employer should consider how much
additional leave is needed (e.g., two weeks, six months, one year?).
51. See Schmidt v. Safeway Inc., 864 F. Supp. 991,996-97, 3 AD Cas. (BNA) 1141, 1145-46 (D.
Or. 1994); Corbett v. National Products Co., 4 AD Cas. (BNA) 987, 990 (E.D. Pa. 1995).
52. See EEOC Enforcement Guidance: Workers' Compensation and the ADA at 16, 8 FEP Manual
(BNA) 405:7391, 7399 (1996) (hereinafter Workers' Compensation and the ADA). See also pp.
37-45, infra, for information on reassignment as a reasonable accommodation.
53. Cf. Kiel v. Select Artificials, 142 F.3d 1077, 1080, 8 AD Cas. (BNA) 43, 44 (8th Cir. 1998).
54. See Criado v. IBM, 145 F.3d 437, 444-45, 8 AD Cas. (BNA) 336, 341 (1st Cir. 1998).
55. But see Matthews v. Commonwealth Edison Co., 128 F.3d 1194, 1197-98, 7 AD Cas. (BNA)
1651, 1653-54 (7th Cir. 1997) (an employee who, because of a heart attack, missed several
months of work and returned on a part-time basis until health permitted him to work full-time,
could be terminated during a RIF based on his lower productivity). In reaching this decision, the
Seventh Circuit failed to consider that the employee needed leave and a modified schedule as
reasonable accommodations for his disability, and that the accommodations became meaningless
when he was penalized for using them.
56. If an employee, however, qualifies for leave under the Family and Medical Leave Act, an
employer may not require him/her to remain on the job with an adjustment in lieu of taking
leave, See 29 C.F,R, § 825.702(d)(1) (1997).
57. See Question 9, supra.
58. For more detailed information on issues raised by the interplay between these statutes, refer
to the FMLA/ADA Fact Sheet listed in the Appendix.
59. Employers should remember that many employees eligible for FMLA leave will not be entitled
to leave as a reasonable accommodation under the ADA, either because they do not meet the
ADA's definition of disability or, if they do have an ADA disability, the need for leave is unrelated
to that disability.
60. 29 C.F.R. §§ 825.214(a), 825.215 (1997),

61. For further information on the undue hardship factors, see infra pp. 55-56.
62.29 C.F.R. § 825.702(c)(4) (1997).
63. 42 U.S.c. §12111 (9) (B) (1994); see Ralph v. Lucent Technologies, Inc., 135 F.3d 166, 172,
7 AD Cas. (BNA) 1345, 1349 (1st Cir. 1998) (a modified schedule is a form of reasonable
accommodation).
64. See US Airways, Inc. v. Barnett, 535 U.S., 122 S. Ct. 1516, 1521 (2002).
65. Certain courts have characterized attendance as an "essential function." See, e.g., Carr v.
Reno, 23 F.3d 525, 530, 3 AD Cas. (BNA) 434, 438 (D.C. Cir. 1994); Jackson v. Department of
Veterans Admin., 22 F.3d 277, 278-79, 3 AD Cas, (BNA) 483, 484 (11th Cir. 1994). Attendance,
however, is not an essential function as defined by the ADA because it is not one of "the
fundamental job duties of the employment position." 29 C.F.R. § 1630.2(n)(1) (1997) (emphasis
added). As the regulations make clear, essential functions are duties to be performed. 29 C.F,R.
§ 1630.2(n)(2) (1997). See Haschmann v. Time Warner Entertainment Co., 151 F.3d 591, 602,
8 AD Cas. (BNA) 692, 701 (7th Cir. 1998); Cehrs v. Northeast Ohio Alzheimer's, 155 F.3d 775,
782-83, 8 AD Cas. (BNA) 825, 830-31 (6th Cir. 1998).
On the other hand, attendance is relevant to job performance and employers need not grant all
requests for a modified schedule. To the contrary, if the time during which an essential function
is performed is integral to its successful completion, then an employer may deny a request to
modify an employee's schedule as an undue hardship.
66. Employers covered under the Family and Medical Leave Act (FMLA) should determine
whether any denial of leave or a modified schedule is also permissible under that law. See 29
C.F.R. § 825.203 (1997).
67. For more detailed information on issues raised by the interplay between these statutes, refer
to the FMLA/ADA Fact Sheet listed in the Appendix.
68. See infra pp. 37-45 for more information on reassignment, including under what
circumstances an employer and employee may voluntarily agree that a transfer is preferable to
having the employee remain in his/her current position.
69. 29 C.F.R. § 825.204 (1997); see also special rules governing intermittent leave for
instructional employees at §§ 825.601, 825.602.
70. 29 C.F,R. §§ 825.209, 825.210 (1997).
71. 42 U,S,c. § 12111(9)(B) (1994); 29 C.F.R. § 1630.2(0)(2)(ii) (1997). See US Airways, Inc.
v. Barnett, 535 U.S., 122 S. Ct. 1516, 1521 (2002).
72. See Dutton v. Johnson County Bd. of Comm'rs, 868 F. Supp. 1260, 1264-65, 3 AD Cas.
(BNA) 1614, 1618 (D. Kan. 1994).
73. See 29 C.F.R. pt. 1630 app. § 1630.15(b), (c) (1997). See also Question 17, supra.
74. But cf. Miller v. Nat'l Casualty Co., 61 F.3d 627, 629-30, 4 AD Cas. (BNA) 1089, 1090 (8th
Cir. 1995) (court refuses to find that employee's sister had requested reasonable accommodation
despite the fact that the sister informed the employer that the employee was having a medical
crisis necessitating emergency hospitalization).

75. For information on how reassignment may apply to employers who provide light duty
positions, see Workers' Compensation and the ADA, supra note 52, at 20-23, 8 FEP Manual
(BNA) 405:7401-03.
76. 42 U.S.c. § 12111(9)(B) (1994); 29 C.F.R. § 1630.2(0)(2)(ii) (1997). See Benson v.
Northwest Airlines, Inc., 62 F.3d 1108, 1114, 4 AD Cas. (BNA) 1234, 1238 (8th Cir. 1995);
Monette v. Electronic Data Sys. Corp., 90 F.3d 1173, 1187, 5 AD Cas, (BNA) 1326, 1338 (6th
Cir. 1996); Gile v. United Airlines, Inc., 95 F.3d 492, 498, 5 AD Cas. (BNA) 1466, 1471 (7th Cir.
1996) .
Reassignment is available only to employees, not to applicants. 29 C.F.R. pt. 1630 app. §
1630.2(0) (1997).
77. 29 C.F.R. pt. 1630 app. § 1630.2(0) (1997); see Haysman v. Food Lion, Inc., 893 F. Supp.
1092, 1104,4 AD Cas. (BNA) 1297, 1305 (S.D. Ga. 1995).
Some courts have found that an employee who is unable to perform the essential functions of
his/her current position is unqualified to receive a reassignment. See, e.g., Schmidt v. Methodist
Hosp. of Indiana, Inc., 89 F.3d 342, 345, 5 AD Cas. (BNA) 1340, 1342 (7th Cir. 1996); Pangalos
v. Prudential Ins. Co. of Am., 5 AD Cas. (BNA) 1825, 1826 (E.D. Pa. 1996). These decisions,
however, nullify Congress' inclusion of reassignment in the ADA. An employee requires a
reassignment only if s/he is unable to continue performing the essential functions of his/her
current position, with or without reasonable accommodation. Thus, an employer must provide
reassignment either when reasonable accommodation in an employee's current job would cause
undue hardship or when it would not be possible. See Aka v. Washington Hosp. Ctr.,156 F.3d
1284, 1300-01, 8 AD Cas. (BNA) 1093, 1107-08 (D.C. Cir. 1998); Dalton v. Subaru-Isuzu
Automotive, Inc., 141 F.3d 667, 678, 7 AD Cas. (BNA) 1872, 1880 (7th Cir. 1998); see also ADA
and Psychiatric Disabilities, supra note 27, at 28, 8 FEP Manual (BNA) 405:7476; Workers'
Compensation and the ADA, supra note 52, at 17-18, 8 FEP Manual (BNA) 405:7399-7400.
78. 29 C.F.R. § 1630.2(m) (1997); 29 C.F.R. pt. 1630 app. §§ 1630.2(m), 1630.2(0)(1997). See
Stone v. Mount Vernon, 118 F.3d 92, 100-01, 6 AD Cas. (BNA) 1685, 1693 (2d Cir. 1997).
79. See Quintana v. Sound Distribution Corp., 6 AD Cas. (BNA) 842, 846 (S.D.N.Y. 1997).
80. See 29 C.F.R. pt. 1630 app. §1630.2(0) (1997); Senate Report, supra note 6, at 31; House
Education and Labor Report, supra note 6, at 63.
81. For suggestions on what the employee can do while waiting for a position to become vacant
within a reasonable amount of time, see note 89, infra.
82. See 29 C.F.R. pt. 1630 app. § 1630,2(0) (1997); see also White v. York Int'l Corp., 45 F.3d
357,362, 3 AD Cas. (BNA) 1746, 1750 (lOth Cir. 1995).
83. See 29 C.F,R, pt. 1630 app. § 1630.2(0) (1997).
84. See US Airways, Inc. v. Barnett, 535 U.S., 122 S. Ct. 1516, 1521, 1524 (2002); see also Aka
v. Washington Hosp. Ctr., 156 F.3d 1284, 1304-05, 8 AD Cas. (BNA) 1093, 1110-11 (D.C. Cir.
1998); United States v. Denver, 943 F, Supp. 1304, 1312, 6 AD Cas. (BNA) 245, 252 (D. Colo,
1996). See also Question 24, supra. .
85.42 U.S.c. § 12111(9)(B) (1994); 29 C.F.R. § 1630.2(0)(2)(ii) (1997); see Hendricks-
Robinson v. Excel Corp., 154 F.3d 685, 695, 8 AD Cas. (BNA) 875, 883 (7th Cir. 1998); see

generally Dalton v. Subaru-Isuzu Automotive, Inc., 141 F.3d 667, 677-78, 7 AD Cas. (BNA)
1872, 1880-81 (7th Cir. 1998).
86. See Gile v. United Airlines, Inc., 95 F.3d 492, 499, 5 AD Cas. (BNA) 1466, 1472 (7th Cir.
1996); see generally United States v. Denver, 943 F. Supp. 1304, 1311-13, 6 AD Cas. (BNA)
245, 251-52 (D. Colo. 1996).
Some courts have limited the obligation to provide a reassignment to positions within the same
department or facility in which the employee currently works, except when the employer's
standard practice is to provide inter-department or inter-facility transfers for all employees. See,
e.g., Emrick v. Libbey-Owens-Ford Co., 875 F. Supp. 393, 398, 4 AD Cas.(BNA) 1, 4-5 (E.D, Tex,
1995). However, the ADA requires modification of workplace policies, such as transfer policies,
as a form of reasonable accommodation. See Question 24, supra. Therefore, policies limiting
transfers cannot be a per se bar to reassigning someone outside his/her department or facility. \
Furthermore, the ADA requires employers to provide reasonable accommodations, including
reassignment, regardless of whether such accommodations are routinely granted to non-disabled
employees. See Question 26, supra.
87. See Hendricks-Robinson v. Excel Corp., 154 F.3d 685, 695-96, 697-98, 8 AD Cas. (BNA)
875, 883, 884 (7th Cir. 1998) (employer cannot mislead disabled employees who need
reassignment about full range of vacant positions; nor can it post vacant positions for such a
short period of time that disabled employees on medical leave have no realistic chance to learn
about them); Mengine v. Runyon, 114 F.3d 415, 420, 6 AD Cas. (BNA) 1530, 1534 (3d Cir.
1997) (an employer has a duty to make reasonable efforts to assist an employee in identifying a
vacancy because an employee will not have the ability or resources to identify a vacant position
absent participation by the employer); Woodman v. Runyon, 132 F.3d 1330, 1344, 7 AD Cas.
(BNA) 1189, 1199 (10th Cir. 1997) (federal employers are far better placed than employees to
investigate in good faith the availability of vacant positions).
88. See Dalton v. Subaru-Isuzu Automotive, Inc., 141 F.3d 667, 678, 7 AD Cas. (BNA)1872,
1881 (7th Cir. 1998) (employer must first identify full range of alternative positions and then
determine which ones employee qualified to perform, with or without reasonable
accommodation); Hendricks-Robinson v. Excel Corp., 154 F.3d 685, 700, 8 AD Cas. (BNA) 875,
886-87 (7th Cir. 1998) (employer's methodology to determine if reassignment is appropriate
does not constitute the "interactive process" contemplated by the ADA if it is directive rather
than interactive); Mengine v. Runyon, 114 F.3d 415, 419-20, 6 AD Cas. (BNA) 1530, 1534 (3d
Cir. 1997) (once an employer has identified possible vacancies, an employee has a duty to
identify which one he is capable of performing).
89. If it will take several weeks to determine whether an appropriate vacant position exists, the
employer and employee should discuss the employee's status during that period. There are
different possibilities depending on the circumstances, but they may include: use of accumulated
paid leave, use of unpaid leave, or a temporary assignment to a light duty position. Employers
also may choose to take actions that go beyond the ADA's requirements, such as eliminating an
essential function of the employee's current position, to enable an employee to continue working
while a reassignment is sought.
90.42 U.s.C. § 12111(9)(b) (1994); 29 C.F.R. pt. 1630 app. § 1630.2(0) (1997). See Senate
Report, supra note 6, at 31 ("If an employee, because of disability, can no longer perform the
essential functions of the job that she or he has held, a transfer to another vacant job for which
the person is qualified may prevent the employee from being out of work and the employer from
losing a valuable worker."), See Wood v. County of Alameda, 5 AD Cas. (BNA) 173, 184 (N.D.
Cal. 1995) (when employee could no longer perform job because of disability, she was entitled to
reassignment to a vacant position, not simply an opportunity to "compete"); cf. Aka v.

Washington Hosp. Ctr., 156 F.3d 1284, 1304-05, 8 AD Cas. (BNA) 1093, 1110-11 (D,C. Cir.
1998) (the court, in interpreting a collective bargaining agreement provision authorizing
reassignment of disabled employees, states that "(a)n employee who is allowed to compete for
jobs precisely like any other applicant has not been "reassigned"); United States v, Denver, 943
F. Supp. 1304, 1310-11, 6 AD Cas. (BNA) 245, 250 (D. Colo. 1996) (the ADA requires employers
to move beyond traditional analysis and consider reassignment as a method of enabling a
disabled worker to do a job).
Some courts have suggested that reassignment means simply an opportunity to compete for a
vacant position. See, e.g., Daugherty v. City of EI Paso, 56 F.3d 695, 700, 4 AD Cas, (BNA) 993,
997 (5th Cir. 1995). Such an interpretation nullifies the clear statutory language stating that
reassignment is a form of reasonable accommodation. Even without the ADA, an employee with
a disability may have the right to compete for a vacant position.
91. 29 C.F.R. pt. 1630 app. § 1630.2(0) (1997).
92. See US Airways, Inc. v. Barnett, 535 U.S., 122 S. Ct. 1516, 1524-25 (2002).
93.Id.
94. Id. at 1525. In a lawsuit, the plaintiff/employee bears the burden of proof to show the
existence of "special circumstances" that warrant a jury's finding that a reassignment is
"reasonable" despite the presence of a seniority system. If an employee can show "special
circumstances," then the burden shifts to the employer to show why the reassignment would
pose an undue hardship. See id.
95.Id.
96. Id. The Supreme Court made clear that these two were examples of "special circumstances"
and that they did not constitute an exhaustive list of examples. Furthermore, Justice Stevens, in
a concurring opinion, raised additional issues that could be relevant to show special
circumstances that would make it reasonable for an employer to make an exception to its
seniority system. See id. at 1526.
97. The discussions and examples in this section assume that there is only one effective
accommodation and that the reasonable accommodation will not cause an undue hardship.
98. See Ralph v. Lucent Technologies, Inc., 135 F.3d 166, 171, 7 AD Cas. (BNA) 1345, 1349 (1st
Cir. 1998).
99. For a discussion on ways to modify supervisory methods, see ADA and Psychiatric
Disabilities, supra note 27, at 26-27, 8 FEP Manual (BNA) 405:7475.
100. See 29 C.F.R. § 1630.2(0)(1)(ii), (2)(ii) (1997) (modifications or adjustments to the
manner or circumstances under which the position held or desired is customarily performed that
enable a qualified individual with a disability to perform the essential functions).
101. Courts have differed regarding whether "work-at-home" can be a reasonable
accommodation. Compare Langon v. Department of Health and Human Servs., 959 F.2d 1053,
1060, 2 AD Cas. (BNA) 152, 159 (D.C. Cir. 1992); Anzalone v. Allstate Insurance Co., 5 AD Cas.
(BNA) 455, 458 (E.D. La. 1995); Carr v. Reno, 23 F.3d 525, 530, 3 AD Cas. (BNA) 434, 437-38
(D.D.C. 1994), with Vande Zande v. Wisconsin Dep't of Admin., 44 F.3d 538, 545, 3 AD Cas.
(BNA) 1636, 1640 (7th Cir, 1995). Courts that have rejected working at home as a reasonable

accommodation focus on evidence that personal contact, interaction, and coordination are
needed for a specific position. See, e.g., Whillock v. Delta Air Lines, 926 F. Supp. 1555, 1564, 5
AD Cas, (BNA) 1027 (N.D. Ga. 1995), aff'd, 86 F,3d 1171, 7 AD Cas. (BNA) 1267 (11th Cir.
1996); Misek-Falkoff v. IBM Corp., 854 F. Supp. 215, 227-28, 3 AD Cas. (BNA) 449, 457-58
(S.D.N,Y. 1994), aff'd, 60 F.3d 811, 6 AD Cas. (BNA) 576 (2d Cir. 1995).
102. See 29 C.F.R. § 1630.15(d) (1997).
103. See Siefken v. Arlington Heights, 65 F.3d 664, 666, 4 AD Cas. (BNA) 1441, 1442 (7th Cir.
1995). Therefore, it may be in the employee's interest to request a reasonable accommodation
before performance suffers or conduct problems occur. For more information on conduct
standards, including when they are job-related and consistent with business necessity, see ADA
and Psychiatric Disabilities, supra note 27, at 29-32, 8 FEP Manual (BNA) 405:7476-78.
An employer does not have to offer a "firm choice" or a "last chance agreement" to an employee
who performs poorly or who has engaged in misconduct because of alcoholism. "Firm choice" or
"last chance agreements" involve excusing past performance or conduct problems resulting from
alcoholism in exchange for an employee's receiving substance abuse treatment and refraining
from further use of alcohoL. Violation of such an agreement generally warrants termination. Since
the ADA does not require employers to excuse poor performance or violation of conduct
standards that are job-related and consistent with business necessity, an employer has no
obligation to provide "firm choice" or a "last chance agreement" as a reasonable accommodation.
See Johnson v. Babbitt, EEOC Docket No. 03940100 (March 28, 1996). However, an employer
may choose to offer an employee a "firm choice" or a "last chance agreement."
104. See ADA and Psychiatric Disabilities, supra note 27, at 31-32, 8 FEP Manual (BNA)
405:7477-78.
105. See Robertson v. The Neuromedical Ctr., 161 F.3d 292, 296 (5th Cir, 1998); see also ADA
and Psychiatric Disabilities, supra note 27, at 27-28, 8 FEP Manual (BNA) 405:7475.
106. While from an employer's perspective it may appear that an employee is "failing" to use
medication or follow a certain treatment, such questions can be complex. There are many
reasons why a person would choose to forgo treatment, including expense and serious side
effects.
107. See Vande Zande v. Wisconsin Dep't of Admin., 44 F.3d 538, 544, 3 AD Cas. (BNA) 1636,
1639 (7th Cir. 1995).
108. See 29 C.F.R. pt. 1630 app. § 1630.9 (1997); see also House Judiciary Report, supra note
6, at 39; House Education and Labor Report, supra note 6, at 65; Senate Report, supra note 6,
at 34.
See, e.g., Taylor v. Principal Fin. Group, Inc., 93 F.3d 155, 165, 5 AD Cas. (BNA) 1653, 1659
(5th Cir. 1996); Tips v. Regents of Texas Tech Univ., 921 F. Supp. 1515, 1518 (N.D. Tex. 1996);
Cheatwood v. Roanoke Indus., 891 F. Supp. 1528, 1538, 5 AD Cas. (BNA) 141, 147 (N.D. Ala.
1995); Mears v, Gulfstream Aerospace Corp., 905 F. Supp. 1075, 1080, 5 AD Cas. (BNA) 1295,
1300 (S.D. Ga. 1995), aff'd, 87 F.3d 1331,6 AD Cas. (BNA) 1152 (11th Cir. 1996). But see
Schmidt v. Safeway Inc., 864 F. Supp. 991, 997, 3 AD Cas. (BNA) 1141, 1146-47 (D, Or. 1994)
(employer had obligation to provide reasonable accommodation because it knew of the
employee's alcohol problem and had reason to believe that an accommodation would permit the
employee to perform the job).

An employer may not assert that it never received a request for reasonable accommodation, as a
defense to a claim of failure to provide reasonable accommodation, if it actively discouraged an
individual from making such a request.
For more information about an individual requesting reasonable accommodation, see Questions
1-4, supra.
109. See Question 5, supra, for information on the interactive process,
110. 29 C.F.R. pt. 1630 app. § 1630.9 (1997).
111. 42 U.S.c. § 12112(d)(3)(B), (d)(4)(C) (1994); 29 C.F.R. § 1630.14(b)(1) (1997). The
limited exceptions to the ADA confidentiality requirements are:
(1) supervisors and managers may be told about necessary restrictions on the work or duties of
the employee and about necessary accommodations; (2) first aid and safety personnel may be
told if the disability might require emergency treatment; and (3) government officials
investigating compliance with the ADA must be given relevant information on request. In
addition, the Commission has interpreted the ADA to allow employers to disclose medical
information in the following circumstances: (1) in accordance with state workers' compensation
laws, employers may disclose information to state workers' compensation offices, state second
injury funds, or workers' compensation insurance carriers; and (2) employers are permitted to
use medical information for insurance purposes. See 29 C.F.R. pt. 1630 app. §1630.14(b)
(1997); Preemployment Questions and Medical Examinations, supra note 27, at 23, 8 FEP
Manual (BNA) 405:7201; Workers' Compensation and the ADA, supra note 52, at 7,8 FEP
Manual (BNA) 405:7394.
112. The discussions and examples in this section assume that there is only one effective
accom modation.
113. See 29 C.F.R. pt. 1630 app. §1630.15(d) (1996); see also Stone v. Mount Vernon, 118 F.3d
92, 101, 6 AD Cas. (BNA) 1685, 1693 (2d Cir. 1997) (an employer who has not hired any
persons with disabilities cannot claim undue hardship based on speculation that if it were to hire
several people with disabilities it may not have sufficient staff to perform certain tasks); Bryant
v. Better Business Bureau of Greater Maryland, 923 F. Supp. 720, 735, 5 AD Cas. (BNA) 625,
634 (D. Md. 1996).
114. See 42 U.S.c. § 12111(10)(B) (1994); 29 C.F,R. § 1630.2(p)(2) (1997); 29 C.F.R. pt. 1630
app. § 1630.2(p) (1997); TAM, supra note 49, at 3.9, 8 FEP Manual (BNA) 405:7005-07.
115. See Senate Report, supra note 6, at 36; House Education and Labor Report, supra note 6,
at 69. See also 29 C.F.R. pt. 1630 app. § 1630.2(p) (1997).
116. See the Appendix on how to obtain information about the tax credit and deductions.
117. See 29 C.F.R. pt. 1630 app. § 1630.15(d) (1997).
118. Failure to transfer marginal functions because of its negative impact on the morale of other
employees also could constitute disparate treatment when similar morale problems do not stop
an employer from reassigning tasks in other situations.
119. See Haschmann v. Time Warner Entertainment Co., 151 F.3d 591, 600-02, 8 AD Cas. (BNA)
692, 699-701 (7th Cir. 1998).

120. See Criado v. IBM, 145 F.3d 437, 444-45, 8 AD Cas, (BNA) 336, 341 (1st Cir. 1998).
121. The ADA's definition of undue hardship does not include any consideration of a cost-benefit
analysis. See 42 U.S.c. § 12111(10) (1994); see also House Education and Labor Report, supra
note 6, at 69 ("(T)he committee wishes to make clear that the fact that an accommodation is
used by only one employee should not be used as a negative factor counting in favor of a finding
of undue hardship.").
Furthermore, the House of Representatives rejected a cost-benefit approach by defeating an
amendment which would have presumed undue hardship if a reasonable accommodation cost
more than 10% of the employee's annual salary. See 136 Congo Rec. H2475 (1990), see also
House Judiciary Report, supra note 6, at 41; 29 C.F.R. pt. 1630 app. § 1630.15(d) (1997).
Despite the statutory language and legislative history, some courts have applied a cost-benefit
analysis. See, e.g., Monette v. Electronic Data Sys. Corp., 90 F.3d 1173, 1184 n.l0, 5 AD Cas.
(BNA) 1326, 1335 n.l0 (6th Cir. 1996); Vande Zande v. Wisconsin Dep't of Admin., 44 F.3d 538,
543, 3 AD Cas. (BNA) 1636, 1638-39 (7th Cir. 1995).
122. See 42 U.S.c. § 12112(b)(2) (1994); 29 C.F.R. § 1630.6 (1997) (prohibiting an employer
from participating in a contractual relationship that has the effect of subjecting qualified
applicants or employees with disabilities to discrimination).
123. See 42 U.S.c. § 12203(b) (1994); 29 C.F.R. § 1630.12(b) (1997).
124. For example, under Title III of the ADA a private entity that owns a building in which goods
and services are offered to the public has an obligation, subject to certain limitations, to remove
architectural barriers so that people with disabilities have equal access to these goods and
services. 42 U.S.c.
§ 12182(b)(2)(A)(iv) (1994). Thus, the requested modification may be something that the
property owner should have done to comply with Title III.
125. US Airways, Inc. v. Barnett, 535 U.S., 122 S. Ct. 1516, 1523 (2002).
126. Id.
127. See Questions 5-10 for a discussion of the interactive process.
This page was last modified on October 22, 2002.
itlReturn to Home Paoe

SECTION

SECTIQ

Title 5 PERSONNEL *
Chapter 5.38 LONG-TERM DISABILITY AN SURVIVOR BENEFIT PLAN
5.38.010 Definitions.
1. 1. "Basic monthly compensation" means the average monthly base rate, as established in
Title 6 of this code, as amended, on salares, hereinafter referred to as "Title 6," for the
position or positions the employee held durng the 12 consecutive months immediately
preceding the qualifying period; provided, however, that in no event shall the basic
monthly compensation include the following:
2. Overtime compensation; or
b. Any lump-sum payoff or reimbursement for unused accumulated overtime, vacation, holiday
time, or sick leave benefits; or
c. Compensation from two or more positions held on a concurent basis.
2. In any case in which the base rate is established in Title 6 on other than a monthly basis, the
equivalent monthly base rate provided for in Chapter 6.14 of Title 6 shall be deemed to be the
monthly base rate for purposes of this section.
B. "Disability beneficiar" means a former employee who has not retired from service under
Retirement Plan E, and who either is receiving disability benefits or is eligible to receive
disability benefits.
C. "Eligible employee" means an employee who becomes totally disabled:
3. As a direct consequence and result of injur or disease arising out of and in the course of
the performance of his or her assigned duties; or
2. After five years of continuous service with the county.
D. "Employee" means an employee of the county of Los Angeles who is a general member of
the Los Angeles County Employees Retirement Association. General member does not include a
safety member.
E. "Qualifying period" means that a qualifying period shall be required with respect to anyone
period of disability and shall be a continuous period equal to the six months, commencing with
the first day on which an eligible employee is absent from work due to a total disability, and
durng which he or she remains totally disabled except as provided below; however, this period
shall not include any time prior to the operative date of the ordinance codified in this chapter. If
the eligible employee ceases to be totally disabled and returs to work for less than an aggregate
of30 days durng a qualifying period, any such cessation of
total disability shall not interrpt
continuity or extend the duration of the qualifying period used to determine the first day on
which benefits commence, provided that the successive absences during the qualifying period are
due to the same cause. In addition, the continuity of
the qualifying period shall not be
interrpted, nor shall the qualifying period be extended, merely because an eligible employee
incurs a disability during such period that arses from a different and unelated cause than that
which initially caused the eligible employee to be absent from work as long as the eligible
employee does not return to active employment at any time during the six months commencing

with the first day on which the eligible employee was first absent from work due to a total
disability.
F. "Retirement plan A, B, C, or D" means any of
the contributory retirement plans established by
the county of Los Angeles pursuant to the County Employees Retirement Law of 1937.
G. "Retirement Plan E" means the optional noncontributory retirement plan made operative for
general members of the Los Angeles County Employees Retirement Association on or after July
1, 1981, by resolution of the board of supervisors of Los Angeles County pursuant to the
Memorandum of Understanding entered into in 1981, by and between the county of Los Angeles
and the County Coalition of Unions.
H. "Total Disability." Durng the qualifying period, and durng the subsequent 24-month period
for which an employee might be eligible to receive benefits under this Plan, "total disability"
means the complete and continuous inability and incapacity of
the employee to perform the
duties of his or her position with the county. After the expiration of24 consecutive months of
eligibility for benefit payments, total disability means that the employee is disabled within the
meanng of the Federal Social Security Act and is eligible to receive or is receiving disability
benefits under the Federal Social Securty Act; provided, however, that for an employee who
makes timely application for disability benefits under the Federal Social Securty Act and who
has not received a final determination regarding disability under that Act, total disability (for the
period prior to the date on which a final determination is made regarding disability) shall mean
the complete and continuous inability and incapacity of the employee to perform the duties of his
or her position with the county. An employee who is not insured for disability benefits (such as
lacking suffcient quarters of covered employment) under the Federal Social Securty Act shall
be considered totally disabled at the end of the 24-month period of eligibility for benefit
payments and during the continuance thereafter ofthe disability ifhe or she is disabled within
the meaning of Section 223(d) of the Federal Social Securty Act. (Ord. 88-0086 § l(a), (b), (c),
1988; Ord. 85-0172 § 4(a), 1985; Ord. 85-0149 §§ 1,2, 1985; Ord. 12406 § 1 (par), 1981: Ord.
4099 Ar. 119 § 24050, 1942.)
5.38.020 Disability benefits.
4. Payment of Benefit. An eligible employee shall begin accruing a basic monthly benefit
on the first day following the expiration ofthe qualifyng period. Except as otherwise
herein provided, such benefit shall be paid as long as the eligible employee's total
disability continues.
B. Basic Monthly Benefit. The basic monthly benefit payable to the eligible employee shall be
the employee's basic monthly compensation multiplied by 60 percent, and then subtracting
therefrom other income benefits specified in subsection C ofthis section.
C. Other Income Benefits. Other income benefits are those benefits identified below to which the
eligible employee is entitled. These other income benefits, payable either monthly or in lump
sum, are:
5. The amount of any salar or other compensation, including sick leave, vacation, or other
pay the eligible employee receives from the county, and 50 percent of any other salar,
compensation or income the eligible employee receives from any other employer, or
otherwise earns.

2. The amount of any benefits with respect to the same disability or disabilities and with respect
to the same period for which the basic monthly benefit is payable under this Plan when such
benefits are provided or payable:
6. By any federal, state, county, municipal or other governental agency; or
b. Pursuant to the Federal Railroad Retirement Act; or
c. As temporary disability benefits under California worker's compensation law;
d. Under any other worker's compensation law; or
e. Under any employer's liability law; or
f. Under the Federal Social Securty Act on the basis ofthe employee's record of wages and selfemployment
income, and not including any amount not paid pursuant to that Act by operation of
42 U.S.c. 424a(a)(2), and payable to the employee without regard to any deductions from such
benefits which may be made:
7. On account of work, or
ii. Because of the employee's refusal to accept rehabilitation; provided, however, that other
income benefits, for puroses ofthis Plan, shall not include any cost-of- living adjustments
applicable to benefits payable under the Federal Social Securty Act subsequent to the
commencement date of such benefits. If the eligible employee is eligible for both retirement
benefits and disability benefits under the Federal Social Securty Act and receives retirement
benefits in lieu of disability benefits, other income benefits shall include the amount of such
retirement benefits.
3. The Amount of Retirement Benefit that the Employee Receives under Retirement Plan A, B,
C, or D. For puroses of this paragraph, such retirement benefits shall not include any cost of
living adjustments granted subsequent to the date any benefits become payable under this Plan.
In the event a disability beneficiary or deceased employee was eligible for retirement benefits
under Retirement Plan A, B, C, or D but was not receiving such benefits, any such benefits that
he or she would have received shall be estimated by the Chief Administrative Offcer for
purposes of calculating any benefit due under this Plan.
4. In the event of other income benefits received in the form of lump-sum payment or payments,
the basic monthly benefit shall not commence or continue until the total of all such basic
monthly benefits otherwise payable under this Plan equals the aggregate amount of such lumpsum
payments.
D. Denial or Cessation of Benefits. Payment of the basic monthly benefit shall cease or not
i
i
commence upon the occurrence of the first of the following events:
8. Attainment of age 65, unless the eligible employee's qualifying period commences on or
after the date he attains age 62, in which case the basic monthly benefit shall cease in
accordance with the following schedule.
Age at Whi~~.. 00 0
Disability 0..
Commences
(Expresse~..
in Years)
--
62
, ~~.._.~. .,.,
I .Maximum Dur~!!~!:o..
I.. of Benefit .. ,v'~v'-n_"y,,"V'o""-~""
Payments (Expressed
I
I
J
in Years)
3-1/2
'-"-_W_--"-'......~_.~w "_'_H_'_'-"-"""-"""""-----"--

..-
m.."_,-"",'"",-""", .. I
,-
i 63 3
ì
64 2-1/2 i o
r- 65 --I 2
66
i
1-3/4
I
I
I 67
i
i
i 1-1/2 ....
I 68 I 1-1/4
i
69 and over I
r-
1
2. Refusal by an eligible employee or disability beneficiary to accept an offer of county
employment which is (a) consistent with his or her work restrictions as determined by the chief
administrative offcer, and (b) appropriate to his or her training, experience, and/or abilities as
determined by the chief administrative offcer.
3. Cessation of total disability, including denial, or termination of, Federal Social Securty
disability benefits at any time after 24 consecutive months of eligibility for benefit payments.
4. Early or normal retirement from the county within the meaning of Retirement Plan E.
5. For an eligible employee or disability beneficiar who is a general member of Retirement Plan
A, B, C, or D, and otherwise eligible for continuation of disability benefits under this Plan,
failure to apply for retirement benefits after 24 months eligibility for disability payments.
6. Failure or refusal of the eligible employee or disability beneficiar to:
9. Timely apply for other benefits for which he may be eligible, including but not limited to
workers' compensation and Federal Social Securty;
b. Furish proof of disability or any other notice required under this Plan;
c. Be examined at the request of the county; or
d. Otherwise cooperate with the county in the determination of benefits under this Plan.
7. Absence from work for six months or more prior to commencement of total disability, unless
the absence is for approved, nonmedical leave.
E. Recurent Disability. If an eligible employee or disability beneficiar returs to county
employment and is disabled again for the same cause within six months from the date of his or
her retu to work, disability benefit payments may be resumed without the eligible employee or
disability beneficiar serving a new qualifying period. Nothing in this provision shall extend the
payment of disability benefits for the original and any subsequent period(s) of disability arsing
from the same cause beyond a total of 24 months of eligibility for benefit payments unless the
eligible employee or disability beneficiar is otherwise eligible for such payments.
F. Retu to Work Par-Time. An eligible employee or disability beneficiar may retu to
county employment of a par-time basis pursuant to a program approved by the chief
administrative officer and may receive disability benefit payments during the period of such
employment; provided, however, that 70 percent of any salar, compensation, or income eared
under such arrangement shall be subtracted from the basic monthly benefit.
G. Cost-of-Living Adjustment.
10. A cost-of-living adjustment shall be applied to the basic monthly disability benefit on the
first day following the completion of 24 months of eligibility for such benefit, and
anually thereafter for as long as the Participant is entitled to benefits under this Plan.
Such adjustment shall equal the anual percentage increase, calculated to the nearest onetenth
of one percent, in the cost of living as measured by the Bureau of Labor Statistics

Consumer Price Index for All Urban Consumers for the Los AngeleslRverside/Orange
County Metropolitan Area for the preceding January 1 S\ provided, however, no increase
resulting from such calculation shall exceed two percent.
2. The provisions of this subsection G of Section 5.38.020 shall be applicable to disability cases
with Qualifying Periods that begin on or after January 1, 2001.
H. LTD Health Insurance.
11. An employee that is eligible for the Choices Plan or
Local 660 Cafeteria Program may elect a disability health insurance benefit hereinafter referred
to as "LTD Health Insurance." LTD Health Insurance shall provide health insurance coverage on
a concurrent basis with the payment of disability benefits under this Section 5.38.020. For each
employee who elects this option, LTD Health Insurance shall provide employee health coverage
to which the employee would otherwise be entitled if not disabled pursuant to the rules set forth
in the applicable Choices Materials as defined in subsection M of Section 5.33.020 or the Local
660 Cafeteria Program Materials as defined in subsection 0 of Section 5.37.020.
2. The cost of L TD Health Insurance shall be borne entirely by the employees who elect this
benefit through the Choices Plan or the Local 660 Cafeteria Program. Such cost shall be paid in
the form of monthly employee contrbutions determined by the County to be the amount
necessary to subsidize 75 percent of the cost ofthe health insurance actually provided under this
provision. The remaining 25 percent shall be paid for by monthly employee payments at the time
the coverage is received.
3. Any employee otherwise eligible to make benefit elections under the Choices Plan or the
Local 660 Cafeteria Program may elect the L TD Health Insurance set forth in this subsection H;
provided, however, that any employee who makes such election while either receiving benefits
under this Plan or completing the Qualifying Period shall not be entitled to actually receive LTD
Health Insurance unless and until the employee retus to work.
4. LTD Health Insurance shall first be available under the Choices Plan and Local 660 Cafeteria
Program beginning Januar 1, 2002. The provisions ofthis Section 5.38.020 H shall first be
reflected on County pay warants issued on or about Januar 15,2002. (Ord. 2000-0074 § 10,
2000: Ord. 89-0158 § 4, 1989; Ord. 88-0086 § l(e) - (h), 1988; Ord. 87-0222 § 4(a), 1987; Ord.
86-0097 § 1, 1986; Ord. 85-0172 § 4(b), 1985; Ord. 85-0149 § 3, 1985; Ord. 84-0003 § 3(a) and
(b), 1984; Ord. 12406 § l(par), 1981: Ord. 4099 Ar. 119 § 24051, 1942.)
5.38.030 Claims.
12. Claim Forms. The county shall furnish the claimant with the appropriate forms for
applying for benefits and for filing proof of disability. If such forms are requested by the
employee and not furnshed in a timely maner by the county, the employee shall be
deemed to have complied with the requirements for filing application for benefits under
this Plan provided a wrtten notice is submitted covering the occurrence and the character
and the extent ofthe disability for which a claim is made within the period of time
provided in this Plan for applying for benefits.

B. Application for Benefits. Application for disability benefits must be filed with the county
within five months after the first day of absence due to total disability or as soon thereafter as is
reasonably possible. However, in the event application is not made within one year from the first
day or absence due to the claimed disability, no benefits shall be paid under this Plan. In
addition, the employee shall be required to apply for disability benefits under the Federal Social
Securty Act and to provide the county with verification of such application within 30 days after
applying for disability benefits under this Plan.
e. Proof of Disability. Written proof covering the occurence, the character, and the extent of
disability must be furnished to the county within 90 days after an application for benefits has
been filed. Failure to furnsh proof within the time required will not invalidate or reduce any
claim if it was not reasonably possible to give proof within such time; provided, that proof is
fuished as soon as reasonably possible. However, in the event the required proof of disability is
not fuished within one year from the first day of absence due to total disability, no benefit shall
be payable under this Plan.
D. Medical Examination. The county may require such additional proof, as is deemed necessar,
including a medical examination at county expense to determine the existence, cause and extent
of any injur or sickness which is the basis for a claim for plan benefits.
E. Determination.
13. If the proof received shows to the satisfaction of the chief administrative offcer, that an
employee is totally disabled, the basic monthly disability benefit shall become payable to
be effective as of the expiration of the qualifying period.
2. Total disability shall in all cases be determined by the chief administrative officer, except that
any final decision ofthe Social Securty Administration concernng a claim for disability benefits
under the Federal Social Securty Act shall be conclusive and binding upon all paries.
3. Ifthe chief administrative offcer determines after medical examination that an eligible
employee or a disability beneficiary is not totally disabled, no disability benefit shall be payable.
F. AppeaL. A claimant may appeal the denial, cessation, or cancellation of a benefit under this
Plan by filing a wrtten notice of appeal with the chief administrative officer within 60 days of
the notice of denial, cessation or cancellation of the benefit. The matter shall then be reviewed by
a hearng officer designated by the county. The hearng officer shall conduct a full and fair
hearng and render a decision, which shall be finaL. (Ord. 88-0086 § l(k), (1), (m), 1988; Ord. 85-
0172 § 4(d), 1985; Ord. 12406 § 1 (par), 1981: Ord. 4099 Ar. 119 § 24053, 1942.)
5.38.050 Exclusions.
Types of Exclusions. The benefits provided for under this Plan shall not be payable for any:
14. Disability or death resulting from or contributed to, by anyone or more ofthe following:
15. Intentionally self-inflcted injures,
2. Paricipation in or consequences of having participated in the commission of a felony,
3. War or any act of war, declared or undeclared,
4. Any exclusion or other condition making an individual ineligible for disability benefits under
the Federal Social Security Act, other than not being insured under that Act; or

B. Disability resulting from, or contributed to, by mental or nervous disorder, drug addiction, or
alcoholism, except while the employee is under regular care in a planed program of observation
and treatment by a licensed physician or surgeon as required by applicable medical standards.
(Ord. 88-0086 § 1(j), 1988; Ord. 87-0222 § 4(b), 1987; Ord. 85-0172 § 4(c), 1985: Ord. 12406 §
1 (part), 1981: Ord. 4099 Ar. 119 § 24052, 1942.)

COUNTY OF LOS ANGELES LONG-TERM DISABILITY PROGRAM
Answers to Commonly Asked Questions
What do i have to do durin~ my disabilty?
You have a very important role in the L TO process. After all, it is your health and your income. To ensure you receive
all of the L TO benefits for which you are entitled, you must:
. Within 30 days of filng your application for benefits, you must apply for disabilty benefits under the
Federal Social Security Act.
. You must provide VPA with proof of your application for Social Security benefits.
. Sign and return all forms to VPA as soon as possible
. See your doctor on a regular basis and follow the treatment plan
. Stay in touch with VPA and your supervisor; provide information as requested
. Return to work when your disabilty ends
When wil my L TD benefits be~in?
The initial waiting period for your L TO benefits is 6 months; beginning with the first day you are absent from work due to
the injury. Processing your L TO Claim depends on how quickly VPA can obtain the required information. The initial
processing involves obtaining information from your department as well as information from your physician. The
average timeframe is two months. Therefore, it is recommended that you start the application process after you have
been off work for four months.
How lon~ does L TD benefits last?
Initially, benefits can last for up to two years as long as you remain disabled from performing the duties of your County
job or until an approved modified job can be developed for you. After two years if you remain disabled and meet the
disability requirements of the Federal Social Security Administration, you could qualify for L TO benefits up to age 65.
If I have auestion about my payment whom should I call?
Call VP A at (800) 786-8600 if you have any questions about your L TO payment.
What happens if VPA cannot aet information from my doctor?
Once your doctor submits the initial Attending Physician Statement, VPA wil request any additional medical records
required to process your claim directly from your doctor. If VPA is unsuccessful in obtaining this information, they may
request your assistance. It is ultimately your responsibilty to provide VPA with the information required to process your
claim. If the objective medical information is not received to support your disability, your claim cannot be approved.
Why do I have to be paid one month in arrears?
The L TO Plan has a provision for reduction due to income you may receive from your employer (available sick time,
vacation, etc.). If you have time on the books, which you are using, L TO wil be paid one month in arrears. If this is the
case you wil receive a check at the end of each month for benefits due from the previous month. As long as you have
useable time on the books, your benefits wil be calculated one month in arrears until your income from the County has
been exhausted.
Why have my payments stopped?
The most frequent reason payments are stopped is because VPA is attempting to obtain information from your doctor's
office to support continuing benefit payments. Payment will also stop if you are no longer disabled.
WARNING: You are reQuired to report to vour emplover or VPA any money that yOU earned
for work durinQ the time covered bv benefit payments under the Countv L TD Plan. If you do
not follow these rules. vou mav be in violation of the law and the penaltv mav be iail or
prison. a fine. and loss of benefits.
ADVERTENCIA: Es necesario Que usted le avise a su patron o a VPA todo dinero Que usted
ha Qanado por trabaiar. durante el tiempo cubierto por su reclamo de incapacidad. Si usted
no siQue estos reQlamentos. Usted puede estar en violacion de la lev v el castiQo pod ria ser
carcel o prision. una multa. v perdida de beneficios.

Title 6 SALARI ES
Chapter 6.20 Leave of Absence
6.20.015 Sick leave eligibilty.
A. Except as provided in this section and Sections 6.20.010 through 6.20.060,
any employee shall be considered eligible for sick leave as provided hereby, and
may utilize such sick leave when compelled to be absent because of disability
resulting from sickness, injury, or pregnancy. Payments made pursuant to this
section and Sections 6.20.010 through 6.20.060, except subsections A 1 and A2,
Band F of Section 6.20.030 and subsection C of Section 6.20.040, shall be
made solely on account of disability resulting from sickness, injury or pregnancy.
B. Employees not eligible for sick leave pursuant to the provisions of this section
and Sections 6.20.010 through 6.20.060 include those employed on an hourly
basis, employed for less than one-half time, employed as a county officer
pursuant to Section 6.28.020, or those employed in positions listed in Section
6.28.060 of this code. (Ord. 93-0019 § 25, 1993.)
6.20.020 Accrual of full-pay sick leave.
A. Effective March 1, 1993, for persons hired on or after July 1, 1986, and
effective January 1, 1994, for persons hired before July 1, 1986, employees who
are eligible for sick leave pursuant to Section 6.20.015 begin to accrue sick
leave on a pay-period basis. At the beginning of each succeeding pay period,
such employees shall accrue sick-leave hours based on the qualifying hours
they have recorded during the preceding pay period. For each qualifying hour
recorded in the preceding pay period, a fraction of an hour of sick leave is
earned and accrued based on the appropriate Sick Leave Accrual Rate, and
subject to Sick Leave Maximum Hours limitations applied each calendar year.
The accumulation of sick leave hours towards the calendar year maximum
begins each January 1 s1. When an employee has accrued the maximum
number of hours, the employee will not be entitled to accrue any additional
hours until the next January 1 st, when accrual starts anew. Sick leave accrued
in one pay period is available for use in the following pay period.
B. The maximum hours of sick leave that an eligible employee represented by
an employee representation unit shall earn and accrue during a calendar year is
specifically designated by the board of supervisors based on the employee's
class, and expressed as a number of days or hours of sick leave. Any qualifying
part-time permanent employee employed on a monthly basis shall be allowed
sick leave in a manner set forth in Chapter 6.20, but in an amount equal to the
item sub fractional amount, as defined by Section 6.28.020. The hours
corresponding to an authorized number of days shall be adjusted as necessary
to reflect assignment to 56-hour workweeks. For 56-hour assignments,

employees shall be entitled to earn 12 hours for every eight hours that a 40-hour
employee shall be entitled to earn.
C. The maximum hours of sick leave that an eligible employee who is not
represented by an employee representation unit shall earn and accrue is 64
hours per calendar year, if assigned to a 40-hour workweek, or 96 hours per
calendar year, if assigned to a 56-hour workweek.
D. For employees assigned to a 40-hour workweek who are authorized to
accrue 96 hours, or for employees assigned to a 56-hour shift who are
authorized to accrue 144 hours, the maximum hours of sick leave that can be
accrued each calendar year is also based on the employee's Sick Leave Years
of Service, as reflected by the employee's continuous service date, or, for an
employee without a continuous service date, the employee's latest hire date.
E. On the anniversary of the date reflecting a change in the Sick Leave Years of
Service as specified in Tables 4 and 5, below, additional hours of sick leave to
which the employee is entitled as a result of the employee's length of service
shall be applied during the remainder of the calendar year and renew at the
beginning of the next calendar year.
F. The following rules provide the accrual rates and maximum hours for the
categories of employees described in the foregoing subsections B, C, and 0:
Rule 1. The Sick Leave Accrual Rate is .050 for employees authorized 64 or 80
hours' sick leave per calendar year and assigned to a 40-hour workweek.
Rule 2. When the workweek of an employee authorized 64 hours of sick leave
per calendar year is adjusted to reflect assignment to a 56-hour workweek, the
Sick Leave Maximum Hours shall be 96 hours and the Sick Leave Accrual Rate
shall be .075.
Rule 3. The Sick Leave Accrual Rate and Sick Leave Maximum Hours of
employees authorized 96 hours' sick leave per calendar year and assigned to a
40-hour workweek shall be as follows:
0-- 1
Sick Leave
Years of
Service
More than 1 to 4
More than 4
Sick Leave
Accrual Rate
.050
.050
.050
Sick Leave
Maximum
Hours
Rule 4. The Sick Leave Accrual Rate and Sick Leave Maximum Hours for
employees authorized 96 hours' sick leave per calendar year whose Maximum
Sick Leave Hours are adjusted to reflect assignment to a 56-hour workweek
shall be:
Sick Leave
Years of
Service
Sick Leave
Accrual Rate
80
88
96
Sick Leave
Maximum
Hours

0-- 1
More than 1 to 4
More than 4
.075
.075
.075
120
132
144
G. Effective May 1, 2005, any employee who forfeited any sick leave at full pay
during the period beginning October 1,2003 through May 31,2005 due to then
existing limits on the accumulation of such time shall be credited on a one-timeonly
basis with additional sick leave at full pay equal to the amount of the
forfeited time.
H. Except for the special, usage-only sick leave granted to certain employees on
January 1, 1994, pursuant to Section 6.20.025 B, sick leave at full pay shall be
deemed used in the reverse order in which it was earned; that is, the most
recently earned sick leave time shall be used first. (Ord. 2005-0038 § 5, 2005:
Ord. 2005-0019 § 15,2005; Ord. 93-0019 § 26,1993.)
6.20.025 Transition from full-pay sick leave provisions in effect prior to
March 1, 1993.
A. For employees with a continuous service date of July 1, 1986, or later, whose
sick leave earnings are credited to them at the beginning of each month based
on active service in the preceding month, the last such crediting shall be given
on March 1, 1993. On that day, the accrual by pay period as set forth in Section
6.20.020A begins for these employees, and employees will be credited with
such additional sick leave, if any, they would have received based on the
application of the relevant Sick-Leave Accrual Rate to qualifying hours as if the
accrual began on January 1, 1993.
B. For employees with a continuous service date earlier than July 1, 1986, who
receive sick leave earnings in advance at the beginning of each year, the last
such crediting shall be given on January 1, 1993. On January 1, 1994, the
accrual by pay period as set forth in Section 6.20.020A begins for these
employees. In addition, on January 1, 1994, each of these employees shall be
granted a number of hours of special full-pay sick leave on a one-time-only
basis. The number of hours to be granted shall be equal to the Sick Leave
Maximum Hours approved for the employee's class pursuant to subsections B or
C of Section 6.20.020 as of January 1, 1994. The special sick leave granted on
January 1, 1994 pursuant to this section is usage-only sick leave, and any of it
which remains unused when the employee terminates county service shall not
be eligible for payment pursuant to Section 6.20.030B. Further, this special sick
leave may not be used until all other 100 percent Current Sick Leave, and all
100 percent Carryover Sick Leave, other than that accumulated prior to January
1,1971, has been exhausted. (Ord. 93-0019 § 27,1993.)

6.20.030 Full-pay sick leave special provisions.
A. In addition to other authorized uses, with the prior approval of the department
head, an employee may use accrued sick leave at full pay for:
1. Non-emergency medical or dental care; or
2. Effective January 1,2000, any personal reason that does not interfere with
the public-service mission of the department or the County to a maximum of 48
working hours in anyone calendar year, or in the case of employees employed
on a 56-hour workweek to a maximum of 72 working hours in anyone calendar
year.
3. Effective January 1, 2004, any personal reason that does not interfere with
the public-service mission of the department or the County to a maximum of 72
working hours in anyone calendar year, or in the case of employees employed
on a 56-hour workweek to a maximum of 108 working hours in anyone calendar
year.
4. In the case of a person compensated on a monthly permanent 9/10 time basis
(Item Sub "0"), any personal reason that does not interfere with the publicservice
mission of the department or the County to a maximum of 36 hours in
anyone calendar year.
B. Upon termination from County service, an employee who holds a permanent
full-time position and who has at least five years of continuous service shall
receive payment for accumulated sick leave at full pay to a maximum of 720
working hours, or in the case of employees assigned to a 56-hour workweek
schedule, to a maximum of 1,080 working hours. Such payment as provided in
Section 6.24.040 shall be computed at the workday hourly rate of pay in effect
on the employee's final day of County service, and shall be equal to the total
time which results from the sum of:
1. All unused sick leave at full pay accumulated prior to January 1, 1971; plus
either:
2. For an employee with a continuous service date of July 1, 1986, or later: onehalf
of all unused sick leave at full pay accumulated on or after January 1, 1971;
or
3. For an employee with a continuous service date earlier than July 1, 1986:
a. One-half of all Carryover Sick Leave at full pay accumulated on or after
January 1, 1971, plus
b. One-half of the Sick Leave Maximum Hours authorized for the employee's
class at the time of termination, less any Current Sick Leave taken.
C. When an employee who holds a permanent, full-time position and who has at
least five years of continuous service is granted a maternity leave of absence,
she may elect to receive all or part of the benefits set forth in subsection B of
this section as if she were terminating.
D. Any employee who is reemployed pursuant to the Civil Service Rules
following a layoff from permanent status or a release from monthly recurrent
status shall be entitled to have restored to him any previously earned and
unused full-pay sick leave not previously paid for pursuant to subsection B or C

of this section. This provision shall not apply to daily as-needed, daily recurrent,
or part-time employees.
E. Notwithstanding any other provision of this Chapter 6.20, persons on a leave
of absence for union business pursuant to the rules of the civil service
commission shall not be credited with sick leave during such leave of absence.
F. Full-time, permanent employees who are approved by the board may be paid
for unused, full-pay sick leave pursuant to the following:
1. An employee who elects to receive payment for unused sick leave as
provided herein shall make his election known in a manner prescribed by
management within one month following the date the employee qualifies for said
payment. In all cases, a sick-leave "day" shall be adjusted as follows if the
employee works other than an eight-hour day:
a. For employees on a 56-hour-per-week basis, a sick-leave "day" shall mean 12
hours;
b. For purposes of this subsection, employees represented by the Joint Council
of Interns and Residents of Los Angeles County (Unit No. 323) shall be paid for
unused full-pay sick leave as if they were full-time permanent employees.
2. For classes approved by the board of supervisors, following each six-month
eligibility period defined in the table below, an eligible employee may, at his
option, be paid for up to three sick-leave days in lieu of carrying such days if the
employee used no sick leave for any reason during the six-month eligibility
period and if by the last calendar day of such period he had completed at least
12 months of continuous service. Such payment shall be computed on the basis
of the workday rate in effect on the last calendar day of the period.
I Beginning Date I
I July 1,2003 I
Ending Date
December 31 , 2003
Eligibilty Periods Defined
I January 1, 2004 I June 30, 2004
I July 1,2004 I
December 31, 2004
I January 1, 2005 I June 30, 2005
I July 1,2005 I
December 31,2005
I January 1, 2006 I June 30, 2006
I July 1,2006 I December 31,2006
(Ord. 2005-0019 § 16,2005; Ord. 2004-0001 § 43,2004: Ord. 2000-0074 § 16,
2000: Ord. 98-0076 § 34, 1998: Ord. 96-0003 § 5, 1996: Ord. 93-0074 § 3,
1993: Ord. 93-0019 § 28, 1993.)

6.20.040 Sick leave at part pay.
A. In addition to the sick leave at full pay provided for in Sections 6.20.010
through 6.20.030, a person who has completed six months or more of
continuous service shall be granted sick leave at part pay in accordance with the
table set forth in subsection E of this section during the remainder of the
calendar year following completion of such six months' service and at the
beginning of each subsequent calendar year, except as otherwise provided for
in Section 6.20.060. Additional Calendar Hours of such part-pay sick leave
which accrue as a result of an employee's length of service shall be allowed
during the remainder of the calendar year and shall renew annually at the
beginning of the calendar year, except as otherwise provided for in Section
6.20.060.
B. Sick leave at part pay may not be used for nonemergency medical or dental
care, and it may not be accumulated.
C. Any person who is under quarantine imposed by legal authority shall be
entitled to a leave under the same conditions and limitations as set forth in the
tables below.
D. Any person who is reemployed following layoff pursuant to the Civil Service
Rules shall be entitled to part-pay sick leave based on his aggregate continuous
service. The amount of part-pay sick leave shall be in accordance with the table
set forth below in subsection E of this section, less any amount of such part-pay
sick leave he may have used in that same calendar year. The provisions of this
subsection 0 shall not apply to a person who returns to work or is otherwise
reinstated following separation for any reason other than layoff.
E. Table of Part-pay Sick Leave.
Table A
Effective March 1, 1993
Number of Calendar Hours Allowed
1 Mont~ly Basis Dail.y Basis I Ii-i-
Cont.inuous 165% Pay 150% Pay 165% 150%
Service Pay Pay
6 months ro~ro~
to 1 year I I I I
2 ~~~¡¡-
to 1 year
years I I I I
years
2 years to
I
5
I
r:12
I
~rsrs
I
5 years to 1224 ~~~
10 years I I I
110 years ~---1336 f3-1240
111 years 1448 1392 1320 ~80

112 years 1448 1448 1320 1320
113 years 1448 1504 1320 1360
114 years 1448 1560 1320 1400-
R5 years 1448 1616 f3-1440
116 years 1448 1672 1320 1480 -
117 years -1448 1728 1320 1520
118 years 1448 1784 1320 1560
119 years 1448 1840 1320 1600
120 years 1448 1896 1320 1640
f2 years 1448 11008 1320 1720
122 years 1448 11120 1320 1800
123 years 1448 11232 1320 1880
124 years 1448 11344 1320 -1960
125 years 1448 11456. j3--11040
126 years 1448 11568 1320 11120-
127 years 1448 11680 1320 11200
128 years 1448 11792 1320 -11280
129 years 1448 11904 1320 -11360-
~~:rears or rr-ro-r440
(Ord. 93-0019 § 29, 1993.)
6.20.050 Sick leave -- Limitations.
A. When an employee has exhausted all sick leave benefits to which he may be
entitled under Sections 6.20.010 through 6.20.040, and in the event that he does
not return to work, he shall not be entitled to additional sick leave benefits
except as may be provided in Section 6.20.060.
B. 1. Sick leave at part pay shall not be allowed to any person until all full-pay
sick leave has been used.
2. Effective January 1, 1980, sick leave at part pay shall not be used until after
five consecutive calendar days, commencing with the first day of absence from
work, due to any single illness or injury, unless such illness or injury results in
hospitalization, in which case part-pay sick leave, subject to subsection C below,
may be used from the first day of such hospitalization.
C. A person who is compelled to be absent because of sickness or injury, or for
nonemergency medical or dental care, may elect to take time off on vacation, or
compensatory time for overtime or holidays worked rather than sick leave,
except that a person on part-pay sick leave must remain on such leave until it is

exhausted, and may not elect any other types of leave unless authorized by his
department head.
D. No compensation shall be paid under this section and Sections 6.20.010
through 6.20.040 and 6.20.060 for any period in excess of the time such person
has been in county service.
E. Sick-leave compensation for persons employed on a daily basis shall be
computed on a five-day workweek basis, unless such person actually works
more than five days per week. (Ord. 6222 Ch. 1 Art. 11 § 230(5), 1953.)
6.20.060 Continuous absence due to ilness or injury.
A. Effective October 26, 1979, a person on a continuous absence because of
sickness or injury which leave begins in one calendar year and extends into the
next calendar year, and who is receiving compensation for sick leave to which
he is entitled for the prior calendar year, shall continue to receive compensation
for any remaining such sick leave in the next calendar year until such sick leave
has been exhausted. Such person shall not be allowed additional sick leave.
B. Effective October 26, 1979, in no case shall a person be compensated for
sick leave at part pay in anyone calendar year in excess of that number of days
of part pay based on his length of service, as set forth in the Table of Part-pay
Sick Leave set forth in Section 6.20.040. (Ord. 6222 Ch. 1 Art. 11 § 230(6),
1953.)
6.20.070 Injuries in the course of employment.
A. Applicability of This Section. The provisions of this section shall apply only to
those industrial-injury cases which the director of personnel or the worker's
compensation appeals board determines to be compensable, and only for such
period of time as the worker's compensation laws of the state of California
require payment of temporary disability, and shall cease when a person leaves
county service other than by disabilty retirement.
B. Eligibility Under This Section.
1. All county employees who have either satisfactorily passed the physical
examination as required by the Civil Service Rules, or who have successfully
completed their initial probationary period shall be eligible.
2. The eligibility of certain classes of employees designated in Section 4850 of
the Labor Code shall be in accordance with the provisions of that section.
C. Compensation and Benefits -- Leaves of One Year or Less.
1. Injuries Occurring On or After January 1, 1981, Affecting Persons Not
Covered by Section 4850 of the Labor Code. Any employee who is absent as a
result of an industrial injury incurred on or after January 1, 1981, and deemed
compensable by the director of personnel or the worker's compensation appeals
board and who is not eligible for compensation under Section 4850 of the Labor
Code, shall receive compensation pursuant to the following:
a. To receive the difference between 70.0 percent of his base salary and the
sum of the benefits prescribed by the worker's compensation laws of the state of

California and earnings from other employment, when such earnings are less
than 70.0 percent of his base salary. Employees shall be eligible to receive such
compensation for a period of one year from the date of injury, but in no case
shall such compensation be paid for a period of time in excess of the employee's
continuous service immediately prior to such injury, except that any person
employed on a daily recurrent basis as an Ocean Lifeguard (Item No. 2923E) or
on an hourly recurrent basis as a Lake Lifeguard (Item No. 2953H) shall be
entitled to receive the benefits set forth in this subsection C for a period not to
exceed .one year from the date of injury or a period equal to the employee's
cumulative active service performed on or after July 1, 1985, whichever is less.
b. Crediting Previously Used Time. In the event an employee is absent due to an
injury incurred on or after January 1, 1981, and the absence is charged to any
previously earned vacation, sick leave, accumulated holiday time or
accumulated overtime, and subsequently the injury is determined to be
compensable by the director of personnel or the worker's compensation appeals
board, 70.0 percent of such vacation, sick leave, holiday time, or overtime shall
be restored to the employee. The remaining 30.0 percent shall be lost.
Restorable time shall be calculated to the nearest 15-minute increment, and
such restoration shall be deemed full recovery of any overpayment resulting
from the operation of this paragraph.
c. Once the injury is determined to be compensable, no employee may use any
previously earned vacation, sick leave, accumulated holiday time, or overtime to
supplement the compensation provided in this section except as provided in
subsections 01 and 02 below.
2. Injuries Affecting Persons Covered by Section 4850 of the Labor Code.
Persons employed in positions which are eligible for compensation under
Section 4850 of the Labor Code shall, in lieu of the compensation set forth in
subparagraph 1 above, be entitled to compensation as provided in said Section
4850.
D. Compensation and Benefits -- After One Year. An employee, who is
compelled to be absent as the result of a compensable industrial injury after one
year from the date of injury or a period equivalent to his continuous service
immediately prior to said date of injury, whichever is less, or, if Section 4850 of
the Labor Code applies, after the termination of the time covered by that section,
may elect one of the following:
1. To receive only those benefits provided under the worker's compensation
laws of the state of California;
2. To use any full-payor part-pay sick leave to which he would be entitled
pursuant to Sections 6.20.010 through 6.20.060 if his injuries had not arisen out
of or in the course of his employment in order to receive the difference between
his sick-leave pay and the sum of his worker's compensation benefits and
earnings from other employment, when such sum is less than said sick-leave
pay. When sick leave has been exhausted, the employee may elect to receive
the alternative set forth in paragraphs 1 or 3 of this subsection 0;
3. To use any previously earned vacation, full-pay sick leave, accumulated
holiday time, or accumulated overtime in order to receive payment equal to the

difference between his base salary and the sum of his worker's compensation
benefits and earnings from other employment when such sum is less than his
base salary. Upon expiration of all such benefits, the employee may elect to
receive the alternatives set forth in paragraphs 1 or 2 of this subsection D.
E. The benefits provided in the worker's compensation laws of the state of
California as referred to in this section shall not include payments made for
hospital, surgical and medical expenses, or payments received as a result of
permanent injury awards.
F. Limitations on Earning and Carryover of Vacation, Sick Leave, and Overtime.
1. Except for safety fire fighting personnel employed in the Fire Department or
as otherwise approved by the Board of Supervisors, no provision of Division 1 of
this title limiting the carryover of vacation and overtime shall apply to employees
during the time they are absent under the provisions of this section or Section
4850 of the Labor Code, nor shall they apply to overtime at the end of the first
calendar year, or to vacation at the end of the first vacation anniversary year of
such employee's return to duty.
2. Employees who are absent under provisions of subsection 01 of this section
shall not earn any vacation or sick leave for the duration of such absence.
G. Leave with Pay for Medical Treatment. Leave with pay for medical treatment
authorized by the director of personnel may be permitted for short periods of
time when temporary disability payments pursuant to this section or Section
4850 of the Labor Code are not made. (Ord. 2005-0038 § 6,2005: Ord. 6222
Ch. 1 Art. 11 § 231, 1953.)

Title 6 SALARI ES
Chapter 6.21 Leave Donation Proqram
6.21.010 Leave donation for nonrepresented employees.
To provide assistance to non represented employees who have a serious or
catastrophic ilness or injury, or who are absent due to an emergency
specifically declared by the board of supervisors, full pay sick leave, vacation
hours, nonelective annual leave, and compensatory time may be transferred
from one or more nonrepresented employees and donated to another
non represented employee, on an hour-for-hour basis, upon the request of both
the receiving employee and the transferring employee(s), and upon approval of
the receiving employee's appointing authority or designee under the following
conditions:
A. To qualify for leave donation the receiving employee must be absent from
work due to injury or the prolonged ilness of the employee, must have
exhausted or wil foreseeably exhaust all earned leave hours including but not
limited to sick leave, vacation (including elective and nonelective annual
leave), compensatory time and holiday credits, and is therefore facing the loss
of salary and benefits. An employee who is receiving benefits for a workrelated
illness or injury under Section 6.20.070 of the County Code or Section
4850 of the Labor Code is not eligible for leave donations. However, an
employee who is only receiving state-mandated workers' compensation
benefits for such illness or injury is eligible.
Employees who are absent from work due to an emergency as declared by the
board of supervisors are eligible to participate in this leave donation program to
the extent such employees have exhausted, or will foreseeably exhaust all
earned leave hours except full and part pay sick leave.
B. The transfers are voluntary. Transfers are to be a minimum of one hour and
in whole hour increments thereafter.
C. Transfers are made from accrued full pay sick leave, vacation, nonelective
annual leave, or compensatory leave balances. All current and deferred
vacation hours and nonelective annual leave may be donated. However, only
that portion of full pay sick leave in excess of 160 hours may be donated.
Transfers for employees who are absent due to an emergency as declared by
the board of supervisors are limited to current and deferred vacation hours and
nonelective annual leave.
D. Transfers shall be allowed to cross departmental lines upon approval of the
appointing authority of the receiving department or his/her designee in
accordance with policies of the receiving departments.
E. Transfers of full pay sick hours will not count as sick leave used for
purposes of applying Section 6.20.030F2 for the donating employee and wil
ll L-

not adversely affect such employee's right to be paid for sick leave hours in
lieu of carrying such hours as provided in that section.
F. Transfers are irrevocable. If any donated hours remain at the end of the
employee's catastrophic or emergency leave, they shall remain for the sole
use of the recipient, as otherwise permitted by the County Code, except that if
the employee dies, the remaining 100% sick leave must be returned to the
donor on a "last in first out basis." However, donated compensatory time that is
not used is deemed lost at the end of the calendar year following the year in
which it was donated, unless otherwise authorized by the chief administrative
officer.
G. The total transfer credits received by an employee shall not exceed 1040
hours, unless specifically approved by the employee's appointing authority or
his/her designee. Any donated leave used by a recipient who is a salariedexempt
employee under the Fair Labor Standards Act must be taken as
provided in Chapter 6.09 of the County Code.
H. Upon approval of a request for donations, the appointing authority (or
his/her designee) shall, at the employee's request, post a notice of the eligible
employee's need for donations on departmental bulletin boards accessible to
employees. Confidential medical information shall not be included in the notice,
unless specifically requested by the eligible employee, and the employee
waives confidentiality as to using such information in writing.
i. Donations shall be administered according to procedures established by the
auditor-controller and chief administrative officer. Signed approvals of the
receiving and donating employees must be provided in accordance with such
procedures before a donation is processed. (Ord. 2004-0073 § 1,2004: Ord.
2004-0001 § 45,2004; Ord. 94-0042 § 1,1994)

DATE:
DEPARTMENT LETTERHAD
TO: Employee#
FROM: Return to Work Section
SUBJECT: COMPENSATION & BENEFITS AFTER ONE YEAR
Injured employees who are off work after one year and are receiving post salary continuation or
Vocational Rehabiltation Maintenance Allowance (VRMA) may be entitled to supplement
workers' compensation benefits with accrued leave benefits.
Civil Service Section 6.20.070.(D) allows an employee who is compelled to be absent as a result
of a compensable industrial injury after one year from the date of injury to elect one of the
following:
1. To receive only those benefits provided under workers' compensation. Please note
that you wil be required to pay for your employee benefits if you are not
receiving a check from your employer.
2. To use any full-payor part-pay sick leave to which one would be entitled if the
injury had not occurred, and/or any previously earned vacation, holiday or
accumulated overtime in order to receive payment equal to the difference between
the base salary and workers' compensation benefits.
TO PAYROLL: The above employee sustained an injury on and has been on a
medical leave of absence since . Please allow the employee
use any available time.
to
Vacation time
Overtime
Holiday time
100% Sick time
65% Sick time
50% Sick time
TO EMPLOYEE: If you elect to supplement your Workers' Compensation benefits, Select the
order you wish to use the time and the effective date . Sign below, retain a copy for
your file, give payroll the original, and forward a copy to your supervisor and the return to work
unit.
Name (printed):
Employee Signature Date:
NOTE: You must contact your payroll clerk to verify all useable hours. Usage of your time will
be continuous until exhausted or you return to work.

SECTION

. SECTION

CHECKLIST FOR lACERA DISABiliTY
When an employee files for a disability retirement with LACERA,
the following information wil be requested of the Return- To-Work
Coordinator:
.. A job profile that indicates the usual duties the employee is
actually required to perform (Usual and Customary duties).
.. A class specification for the employee's payroll item.
.. All accident reports filed with the employee's records.
.. All medical reports or certifications filed with the employee's
records.
.. The telephone number of the payroll office.
.. The date on which the employee's sick leave benefits expire.
.. Personnel file - Department issued.

L~..CERA &
Sections 31725.5 & 31725.6 (Salary Supplement Provisions)
Sections 31725.5 and 31725.6 of the County Employees' Retirement Law provide a County
employee, who is disabled from the original position"with the capabilty of being reassigned
(rehabiltated) to a lesser position, a salary supplement up to the amount of disability
retirement allowance:' This employee must meet all criteria for regular disabilty retirement.
The issue before the Board of Retirement is- the same as any other disability retirement,
with the burden of proof being placed on the applicant.
The utilzation of these two Sections of the Retirement Law requires that several conditions
must be met:
A) The applicant must be found to be disabled by the Board of Retirement.
1. Due to Service-connected causes (Section 31725.6)
2. Due to Nonservice-connected causes (Section 31725.5)
B) The criteria for the supplement is the same as for a disability retirement.
C) The applicant must be WILLING to accept the lesser position.
D) The department must have a position to accommodate the applicant's work
restrictions.
1. Applicant can be placed on a 'Y' rate until the Retirement Board action.
2. Applicant is voluntarily demoted to the lesser position.
Mechanically speaking, upon the Retirement Board's action the department is notified of
the Board's action and an effective date for the supplement is established.
The effective date is determined by:
1. If on 'Y' rate - the 1 st of the following month.
2. If demoted, either the date of the disability application or the date of the
demotion, which ever is the latest date. (Section 31724)
The retirement staff then determines the amount of the supplement and initiates a warrant
to the applicant on a monthly basis. (Adjustments are made for cost of living raises).
At the time an applicant on the supplement finds that he/she can no longer perform the
duties of the lesser position, he/she should contact the Disability Section to retire. At this
time the employee, and only the employee, may voluntarily file for total disability retirement.
All that is required is a letter from the employee that he/she can no longer work.
The Board then grants the retirement.

1937 Act of the Government Code
Disability Retirements
31725. Permanent incapacity for the performance of duty shall in
all cases be determined by the board.
If the medical examination and other available information do not
show to the satisfaction of the board that the member is
incapacitated physically or mentally for the performance of his
duties in the service and the member i s application is denied on this
ground the board shal 1 give notice of such denial to the employer.
The employer may obtain judicial review of such action of the board
by filing a petition for a writ of mandate in accordance with the
Code of civil Procedure or by joining or intervening in such action
filed by the member within 30 days of the mailing of such notice. If
such petition is not filed or the court enters judgment denying the
writ, whether on the petition of the employer or the member, and the
employer has dismissed the member for disability the employer shall
reinstate the member to his employment effective as of the day
following the effective date of the dismissal.
31725.5. If the board finds, on medical advice, that a member in
county employment, although incapacitated for the performance of his
duties, is capable of performing other duties in the service of the
county, the member shall not be entitled to a disability retirement
allowance if any competent authority in accordance with any
applicable civil service or merit system procedures offers and he
accepts a transfer, reassignment, or other change to a position with
duties within his capacity to perform with his disability. If this
new position returns to the member compensation less than that of the
position from which he was disabled, the board, in lieu of a
disability retirement allowance, shall pay him the difference in such
compensation until the compensation of the new position equals or
exceeds the compensation (including later changes) of the former
position, but such amount shall not exceed the amount to which he
would otherwise be entitled as a disability retirement allowance.
Such payments in lieu of disability retirement allowance shall be
considered as a charge against county advance reserve for current
service.
If a new position cannot be arranged at the time of eligibility
for disability retirement allowance, such disability retirement
allowance to which the member is entitled under this article shall be
paid until such time as a new position is available and accepted.
If a disability retirement allowance is paid and the member later
accepts such a new position, the period while on disability
retirement shall not be considered as breaking the continuity of
service and his rate of contributions shall be based on the same age
as it was at the date of disability. The member i s accumulated
contributions shall be the same as at the date his disability
retirement began less the amount charged to his accumulated normal
contributions.
Nothing in this section shall be construed to require a member to
accept reassignment or transfer in lieu of a disability retirement
allowance.
The provisions of this section become effective in any county only
when the board of supervisors adopts an ordinance providing for

their implementation by the board of retirement which may include
application to persons retired for disability before such effective
date.
The provisions of this section shall only apply to members
eligible to retire for nonservice-connected disability.
31725.6. (a) When the board finds, based on medical advice, that a
member in county service is incapacitated for the performance of the
member i s duties, the board shall determine, based upon that medical
advice, whether the member is capable of performing other duties. If
the board determines that a member, although incapacitated for the
performance of the member i s duties, is capable of performing other
duties, the board shall inform the appropriate agency in county
service of its findings and request that the agency immediately
initiate a suitable rehabilitation program for the member pursuant to
Section 139.5 of the Labor Code, whereby the member could become
qualified for assignment to a position in county service consistent
with the rehabilitation program.
(b) When the appropriate agency in county service receives such a
request from the board, the agency shall immediately refer the member
to a qualified rehabilitation representative for vocational
evaluation. During the course of the evaluation, the rehabilitation
representative shall consult with the appropriate agency in county
service to determine what position, if any, in county service would
be compatible with the member's aptitudes, interests, and abilities
and whether rehabilitation services will enable the member to become
qualified to perform the duties of the position.
(c) Upon completion of the vocational evaluation of the member,
the rehabilitation representative shall develop a suitable
rehabilitation plan and submit the plan for concurrence by the member
and the appropriate agency in county service and, thereafter, the
agency shall forward the plan to the Division of Industrial Accidents
for approval pursuant to Section 139.5 of the Labor Code.
(d) Upon receipt of approval of the rehabilitation plan, the
appropriate agency in county service shall notify the board that the
agency is either proceeding to implement an approved rehabilitation
plan that will qualify the member for a position in county service
specified in the plan or is unable to provide a position in county
service compatible with the approved rehabilitation plan.
(e) Upon commencement of service by the member in the position
specified in the approved rehabilitation plan, the member shall not
be paid the disability retirement allowance to which the member would
otherwise be entitled during the entire period that the member
remains in county service. However, if the compensation rate of the
position specified in the approved rehabilitation plan is less than
the compensation rate of the position for which the member was
incapacitated, the board shall, in lieu of the disability retirement
allowance, pay to the member a supplemental disability allowance in
an amount equal to the difference between the compensation rate of
the position for which the member was incapacitated, applicable on
the date of the commencement of service by the member in the position
specified in the approved rehabilitation plan, and the compensation
rate of the position specified in the plan, applicable on the same
date. The supplemental disability allowance shall be adjusted
annually to equal the difference between the current compensation

ate of the position for which the member was incapacitated and the
current compensation of the position specified in the approved
rehabilitation plan. The supplemental disability allowance payments
shall commence upon suspension of the disability retirement allowance
and the amount of the payments shall not be greater than the
disability retirement allowance to which the member would otherwise
be entitled. Supplemental disability allowance payments made
pursuant to this section shall be considered as a charge against the
county advance reserve for current service, and all of these payments
received by a member shall be considered as a part of the member's
compensation within the meaning of Section 31460.
(f) From the time that the member is eligible to receive a
disability retirement allowance until the appropriate agency is able
to provide the position in county service specified in the approved
rehabilitation plan, and the member has commenced service in that
position, the disability retirement allowance to which the member is
entitled under this article shall be paid. Upon commencement of
service by the member in the position specified in the approved
rehabilitation plan, the period during which the member was receiving
disability retirement payments shall not be considered as breaking
the continuity of the member i s service, and the rate of the member 's
contributions shall continue to be based on the same age at entrance
into the retirement system as the member's rates were based on prior
to the date of the member 's disability. The member i s accumulated
contributions shall not be reduced as a result of the member
receiving the disability retirement payments, but shall be increased
by the amount of interest that would have accrued had the member not
been retired.
(g) Notwithstanding Section 31560, a member whose principal
duties, while serving in the position for which the member was
incapacitated, consisted of activities defined in Section 31469.3
shall, upon commencement of service by the member in the position
specified in the approved rehabilitation plan, continue to be
considered as satisfying the requirements of Section 31560,
notwithstanding the actual duties performed during the entire period
that the member remains in county service.
(h) If, within one year from the date that the member has been
eligible for a disability retirement allowance, the appropriate
agency in county service has offered to the member, in writing, the
position specified in the rehabilitation plan which had previously
been concurred, in writing, by the member and approved by the
Division of Industrial Accidents pursuant to Section 139.5 of the
Labor Code, the member shall, within 30 days of receipt of the
notice, report for duty at the location specified in the notice. If
the member refuses to report for duty within the time specified, the
appropriate agency in county service may apply to the board to have
the member i s allowance discontinued. The board shall be authorized
to discontinue the member iS disability retirement allowance if based
upon substantial evidence of the refusal of the member to report to
work without reasonable cause. However, the board shall not be
authorized to impair any other of the rights or retirement benefits
to which the member would otherwise be entitled.
(i) This section shall apply only to members who were
incapaci tated for the performance of the member i s duties prior to
January 1, 2004, and who are eligible to retire for service-connected
disability.

31725.65. (a) When the board finds, based on medical advice, that a
member in county service is incapacitated for the performance of the
member i s duties, the board shall determine, based upon that medical
advice, whether the member may be capable of performing other duties.
If the board determines that a member, although incapacitated for
the performance of the member i s duties, is capable of performing
other duties, the board shall notify the appropriate agency in county
service of its findings.
(b) When the appropriate agency in county service receives that
notification from the board, the agency shall immediately inform the
member of any vacant county positions that may be suitable for the
member, consistent with his or her disability, and shall consult with
the member in an effort to develop a reemployment plan that shall
identify what position, if any, in county service would be compatible
with the member's aptitudes, interests, and abilities.
(c) Upon approval by the member of the reemployment plan, the
appropriate agency in county service shall notify the board that the
agency is proceeding to implement the approved reemployment plan.
(d) Upon commencement of service by the member in the position
specified in the approved reemployment plan, the member shall not be
paid the disability retirement allowance to which the member would
otherwise be entitled during the entire period that the member
remains in county service. However, if the compensation rate of the
position specified in the approved reemployment plan is less than the
compensation rate of the position for which the member was
incapacitated, the board shall, in lieu of the disability retirement
allowance, pay to the member a supplemental disability allowance in
an amount equal to the difference between the compensation rate of
the position for which the member was incapacitated, applicable on
the date of the commencement of service by the member in the position
specified in the approved reemployment plan, and the compensation
rate of the position specified in the plan, applicable on the same
date. The supplemental disability allowance shall be adjusted
annually to equal the difference between the current compensation
rate of the position for which the member was incapacitated and the
current compensation of the position specified in the approved
reemployment plan. The supplemental disability allowance payments
shall commence upon suspension of the disability retirement allowance
and the amount of the payments shall not be greater than the
disability retirement allowance to which the member would otherwise
be entitled. Supplemental disability allowance payments made
pursuant to this section shall be considered as a charge against the
county advance reserve for current service, and all of these payments
rece i ved by a member shal 1 be cons idered as a part of the member i s
compensation within the meaning of Section 31460.
(e) From the time that the member is eligible to receive a
disability retirement allowance until the appropriate agency is able
to provide the position in county service specified in the approved
reemployment plan, and the member has commenced service in that
position, the disability retirement allowance to which the member is
entitled under this article shall be paid. Upon commencement of
service by the member in the position specified in the approved
reemployment plan, the period during which the member was receiving
disability retirement payments shall not be considered as breaking
the continuity of the member's service, and the rate of the member i s
contributions shall continue to be based on the same age at entrance

into the retirement system as the member's rates were based on prior
to the date of the member i s disability. The member i s accumulated
contributions shall not be reduced as a result of the member
recei ving the disability retirement payments i but shall be increased
by the amount of interest that would have accrued had the member not
been retired.
(f) Notwithstanding Section 31560, a member whose principal
duties, while serving in the position for which the member was
incapacitated, consisted of activities defined in Section 31469.3
shall, upon commencement of service by the member in the position
specified in the approved reemployment plan, continue to be
considered as satisfying the requirements of Section 31560,
notwithstanding the actual duties performed during the entire period
that the member remains in county service.
(g) This section shall apply only to members who are incapacitated
for the performance of the member i s duties on or after January 1,
2004, and who are eligible to retire for service-connected
disability.
31725.7. (a) At any time after filing an application for disability
retirement with the board, the member may, if eligible, apply for,
and the board in its discretion may grant, a service retirement
allowance pending the determination of his or her entitlement to
disability retirement. If he or she is found to be eligible for
disability retirement, appropriate adjustments shall be made in his
or her retirement allowance retroactive to the effective date of his
or her disability retirement as provided in Section 31724.
(b) This section shall not be construed to authorize a member to
receive more than one type of retirement allowance for the same
period of time nor to entitle any beneficiary to receive benefits
which the beneficiary would not otherwise have been entitled to
receive under the type of retirement which the member is finally
determined to have been entitled. In the event a member retired for
service is found not to be entitled to disability retirement he or
she shall not be entitled to return to his or her job as provided in
Section 31725.
(c) If the retired member should die before a final determination
is made concerning entitlement to disability retirement, the rights
of the beneficiary shall be as selected by the member at the time of
retirement for service. The optional or unmodified type of allowance
selected by the member at the time of retirement for service shall
also be binding as to the type of allowance the member receives if
the member is awarded a disability retirement.
(d) Notwithstanding subdivision (c), if the retired member should
die before a final determination is made concerning entitlement to
disability retirement, the rights of the beneficiary may be as
selected by the member at the time of retirement for service, or as
if the member had selected an unmodified allowance. The optional or
unmodified type of allowance selected by the member at the time of
retirement for service shall not be binding as to the type of
allowance the member receives if the member is awarded a disability
retirement. A change to the optional or unmodified type of allowance
shall be made only at the time a member is awarded a disability
retirement and the change shall be retroactive to the service
retirement date and benefits previously paid shall be adjusted. If a

change to the optional or unmodified type of allowance is not made,
the benefit shall be adjusted to reflect the differences in
retirement benefits previously received. This paragraph shall only
apply to members who retire on or after January 1, 1999.
31725.8. If any applicant for service-connected disability
retirement is found by the board to be permanently physically or
mentally incapacitated for the performance of his duties but not
because of injury or disease arising out of and in the course of his
employment, he may apply for, and the board in its discretion may
grant, a non-service-connected disability retirement allowance while
he is pursuing any rehearing before the board or judicial review
concerning his right to service-connected disability retirement. If
his disability is finally determined to have been service-connected,
appropriate adjustments shall be made in his retirement allowance
retroactive to the effective date of his disability retirement.
If any member dies after electing to receive non-service-connected
disability retirement and before the question of his entitlement to
service-connected disability retirement is finally resolved, the
rights of his beneficiary shall be those selected by the member at
the time he elected to receive non-service-connected disability
retirement.

SECTION T

Title 5 PERSONNEL
Appendices
Part 2
9.08 Partially or fully incapacitated employees. Whenever, upon medical reevaluation or
competent medical or legal evidence, an employee who has previously qualified is
found to be unable to perform the duties of his/her position satisfactorily, due to a
medical incapacity of a continuing nature:
A. The employee may submit a request to the appointing authority for reassignment,
voluntary demotion, or transfer to a position for which the employee has the
qualifications. Any voluntary demotion under this rule must be with the approval of the
director of personneL.
B. If no action is taken under paragraph A of this Rule, the director of personnel shall,
consistent with his determination of the employee's medical capacities, recommend the
most appropriate of the following alternatives:
1. Return of the employee to suitable work through one of the following means:
a. Modification of the employee's duties or change of his/her assignment,
b. Change of classification or reduction to another position in the employee's
department,
c. Transfer to a position in another department. Where appropriate, this
recommendation will include a retraining program;
2. Disability retirement of the employee, in accordance with the employee's eligibility
under appropriate provisions of the Government Code;
3. Release of the employee in accordance with paragraph C of this Rule. The
appointing authority considering the recommendations of the director of personnel may
change classification or reduce the employee to a position for which the employee is
qualified or for which the employee can be trained within a reasonable period of time.
Where the appointing authority indicates that he/she cannot follow the recommendation
of the director of personnel for a change of classification or reduction, the director shall
place the employee on appropriate departmental reemployment lists, provided the
employee's performance has been competent or better. Such lists shall only be
applicable to positions that are compatible with the employee's medical capacities, and
training and/or experience.
C. If there is no suitable position in which the employee can perform satisfactorily, the
appointing authority may release the employee, subject to the applicable provisions of
Rule 18, said release to be without prejudice as to reemployment should the employee's
condition improve. (Ord. 88-0020 § 1 (part), 1988.)

GUIDELINES FOR DOCUMENTATION OF MEDICAL RELEASE
Civil Service Rule 9.08
Partially or Fully Incapacitated Employees
Civil Service Rule 9.08 (C), found in Appendix 1, Title 5 of the County Code, grants the Chief
Administrative Office authority to approve the medical release of partially or fully incapacitated
employees. In recommending such a release, the Disabilty Management Programs staff wil
review supporting documentation to ensure compliance with Civil Service Rule 9.08 (A) and (B).
If a medical release is sought pursuant to Civil Service Rule (CSR) 9.08 (C), and the employee
has met the social Security criteria for total disability, please send your request to the Chief
Administrative Offce, and include the letter from VPA confirming this. This mainly applies to
members of Retirement Plan E. It may apply to contributory plan members (A through D) in rare
instances.
If you are unable to release an employee based upon the above, and County placement is
unsuccessful, management must demonstrate its attempts to comply with the provisions of CSR
9.08 (A) and (B).
To assist management, Personnel Officers, Return-to-Work Coordinators, and supervisory
personnel to meet the requirements of the CSR 9.08 (C), the foHewing represents minimum
documentation staff will need to approve a medical release. The following list is not meant to be
all inclusive, as each situation may necessitate variances in information.
. Job description
. Summary of recent job search efforts within and outside the department
. Statement regarding previous job, transferable skils, education, and training
. Doctor's statement indicating employee's inabilty to return to gainful employment
. Statement indicating if employee has or has not returned to work based upon the
permanent work restrictions
. Retirement plan membership
. Written confirmation of interactive meeting held with employee to discuss options under
CSR 9.08
. Written confirmation from VPA that employee qualifies for benefits under the Social
Security Act
. Statement indicating if employee can or cannot return to work based upon vocational
rehabilitation plan objective
. Documentation from Occupational Health Programs confirming employee's inability to
return to work, if applicable (non-occupational injury/illness case or occupational
ilness/injury of Workers' Compensation Appeals Board no longer has jurisdiction)
Please send all correspondence to:
Mr. Rocky Armfield, Assistant Administrative Officer
Chief Administrative Office, Risk Management Branch
3333 Wilshire Blvd., 8th Floor
Los Angeles, CA 90010

MEDICAL RELEASE / RETIREMENT PLANS A THROUGH D
The County Retirement Act of 1937 indicates employees who are eligible to file
application for disability retirement (members of plans A through D) may not be
medically separated from County service. In lieu of medical separation the employer
must file an application for disability retirement on the employee's behalf (Government
Code Section 31721).
Under certain circumstances, however, a medical release may be the only remaining
alternative by which the County can clear the item. Following are the circumstances and
situations under which a department may consider medical release for a member of
Retirement Plan A through D as the only appropriate alternative;
1. The department has clear and undisputed medical evidence that the
employee is permanently unable to perform the essential duties of their job.
2. The department has clear, convincing and complete documentation that there
is no suitable, alternative or modified work available that can be provided for
the employee on a permanent basis.
3. The department has filed an application for disability retirement on behalf of
the employee (usually done because the employee is unwillng to file such
application) .
4. The department has received written notice from the Retirement Board that
the retirement process cannot be completed and no decision on the
retirement application can be made because the employee has refused to
cooperate in the required steps of the disability retirement process.
If all of the above items are present the department should review to insure compliance
with the requirements of Civil Service Rule 9.08 and request concurrence from the
Director of Personnel that medical release is the only appropriate, remaining alternative.
Once written concurrence is received the department may proceed with the medical
release in accordance with Rule 9.08 paragraph C. The following elements form the
basis of the separation;
1. There is clear medical information that the employee is medically precluded
on a permanent basis from performing the essential duties of their job.
2. No suitable alternate or modified permanent work is available.
3. The department has filed an application for disability retirement on the
employee's behalf in compliance with the County Retirement Act (California
Government Code Section 31721).
4. The Retirement Board has notified the department that because of the
employee's refusal to cooperate in the required disabilty retirement process,
the process has been suspended and no decision can be made on the
retirement application.

Under no circumstances can an employee be medically separated if the Retirement
Board has completed their process and denies the application on the basis that the
employee is not disabled from the essential duties of his/her job. Government Code
Section 31725 indicates that If the Retirement Board finds the employee is not disabled
the department must either return the employee to work or appeal the Board's decision
by filing a writ of mandate in Superior Court.

Date
Employee Name
Address
Dear Employee:
DEPARTMENT LETTERHEAD
Sample Letter
This is to notify you of our intent to medically release you, without prejudice, from your
position of , pursuant to Civil Service Rule 9.08(c) effective
The factual support for this release includes, but is not limited to the following:
. You have met the Social Security criteria for total disability. Also, as a member
of Retirement Plan E, you are not eligible for disability retirement.
. You are entitled to Long Term Disabilty payments until you reach the age of 65,
as long as you continue to remain disabled as defined by the L TD plan.
This release pursuant to Civil Service Rule 9.08 (c) is without prejudice as to reemployment
should your medical condition improve.
Should you need further clarification regarding the above, please contact
at
All written materials, reports and any documents upon which this action is based are in
your file. If you wish to respond to this intent to release before it is
imposed, please notify me at on or before . Failure to
respond to this notice will result in your medical release effective
Sincerely,

DEPARTMENT LETTERHEAD
Sample Letter
Date Certified Mail
First Class Mail
Employee name
Address
Address
Dear Employee:
In accordance with the recommendation of the Chief Administrative Office and the
provisions of Civil Service Rule 9.08 C, you are herewith notified that at the close of
business on , you are released from your position of at
Department Name and from County service.
You were advised in a certified letter dated
release you from County service. You were given until
intended action.
, of our intention to medically
to respond to this
You are being released because you are totally disabled as defined by the Federal
Social Security Act's criteria for total disability. Further, VPA Inc. has advised us that
because you are deemed totally disabled, you will continue to receive Long Term
Disabilty (L TD) benefits until age 65 as long as you continue to remain totally disabled
as defined by the L TD plan. Therefore this release is without prejudice as to
reemployment should your condition improve.
Civil Service Rules give you the right to appeal this action and request a hearing before
the Civil Service Commission. Your appeal letter must be in writing, signed by you or
your representative, must give your current mailing address, and must state the ruling or
action you are appealing. Written requests for a hearing must be sent within fifteen (15)
business days from the date of this letter to the Civil Service Commission, 222 North
Grand Ave., Room 522, Los Angeles, California 90012. A copy of your letter should
also be sent to Director of Human Resources/Personnel
Officer, Department name and address.
Sincerely,

Date
Employee Name
Employee Address
Dear Employee:
COUNTY LETTERHEAD
On , you were served with a Notice of Intent to deem you as
resigned from your County employment. You were given an opportunity to
meet with , to respond to the pending action against you.
Paragraph or sentence explaining if the employee responded or not.
You are hereby notified that you are deemed to have resigned from your
position of , effective
This action is based upon your absence from work without authorization since
, and your failure to return to work on , as
ordered: Los Angeles County Code Section 5.12.030, states:
Sincerely,
'When a County officer or employee, without prior
authorization, is absent or fails to discharge his regularly
assigned duties for such period of time that it appears likely he
intends to resign pursuant to subsection A of Section
5.12.020, the appointing officer of such affected officer or
employee shall service upon that officer or employee, either
personally, by telegraph, or by first class mail addressed to the
most recent address furnished to the appointed officer by the
affected officer or employee, a notice in writing stating that
failure of the officer or employee to resume the discharge of
his duties on or before the commencement of the working day
stated therein shall constitute such resignation."
DEPARTMENT HEAD

Date
Employee Name
Employee Address
Dear Employee:
COUNTY LETTERHEAD
You have been absent from work without authorization since
are hereby notified that you are ordered to return to work on
are to report to name. location. address and date to report.
. You
. You
On , you were notified by that you received
temporary work restrictions, which are compatible with your usual and customary
assignment. You were also notified to report to work on , and as of
this date, we have not received any response from you.
Therefore your failure to comply with this order to return to work on
result discipline up to and including termination proceedings, pursuant to the Los
Angeles County Code Section 5.12.030, which is attached.
If for any valid reason you cannot return to work by , you must
obtain an offcial authorization in writing from your treating physician to be absent.
If you have any questions regarding this matter, please contact name. title. phone
number.
Sincerely,
DEPARTMENT HEAD
, wil

Date
Employee Name
Employee Address
Dear Employee:
DEPARTMENT LETTERHEAD
The Department has received notification from TP A that temporary
work restrictions have been imposed. We believe they are compatible with your usual
and customary work assignment. You are hereby notified that you are ordered to return
to work on . You are to report to Name. location. time.
Your failure to comply with this order may result in disciplinary action up to and including
discharge from County Service.
Should you have any questions regarding your disability status, please contact
at
Sincerely,
DEPARTMENT HEAD

Date
Employee Name
Address
Dear Employee:
DEPARTMENT LETTERHEAD
Sample Letter
This is to notify you of our intent to medically release you, without prejudice, from your
position of , pursuant to Civil Service Rule 9.08(c) effective
The factual support for this release includes, but is not limited to the following:
. You have met the Social Security criteria for total disability. Also, as a member
of Retirement Plan E, you are not eligible for disability retirement.
. You are entitled to Long Term Disability payments until you reach the age of 65,
as long as you continue to remain disabled as defined by the L TO plan.
This release pursuant to Civil Service Rule 9.08 (c) is without prejudice as to reemployment
should your medical condition improve.
Should you need further clarification regarding the above, please contact
at
All written materials, reports and any documents upon which this action is based are in
your file. If you wish to respond to this intent to release before it is
imposed, please notify me at on or before . Failure to
respond to this notice wil result in your medical release effective
Sincerely,

DEPARTMENT LETTERHEAD
Sample Letter
Date Certified Mail
First Class Mail
Employee name
Address
Address
Dear Employee:
In accordance with the recommendation of the Chief Administrative Office and the
provisions of Civil Service Rule 9.08 C, you are herewith notified that at the close of
business on , you are released from your position of at
Department Name and from County service.
You were advised in a certified letter dated
release you from County service. You were given until
intended action.
, of our intention to medically
to respond to this
You are being released because you are totally disabled as defined by the Federal
Social Security Act's criteria for total disability. Further, VPA Inc. has advised us that
because you are deemed totally disabled, you wil continue to receive Long Term
Disabilty (L TO) benefits until age 65 as long as you continue to remain totally disabled
as defined by the L TO plan. Therefore this release is without prejudice as to
reemployment should your condition improve.
Civil Service Rules give you the right to appeal this action and request a hearing before
the Civil Service Commission. Your appeal letter must be in writing, signed by you or
your representative, must give your current mailing address, and must state the ruling or
action you are appealing. Written requests for a hearing must be sent within fifteen (15)
business days from the date of this letter to the Civil Service Commission, 222 North
Grand Ave., Room 522, Los Angeles, California 90012. A copy of your letter should
also be sent to Director of Human Resources/Personnel
Officer, Department name and address.
Sincerely,

, ç-'"
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", ,
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American with Disabilties Act (ADA)
Gordon Anthony, Senior Deputy
Office of Affirmative Action Compliance
500 West Temple Street, Room 780
Los Angeles, CA 90012
Phone: (213) 202-5826
Website: ww.usdoj.gov/crtada/adahoml.htm
American with Disabilties Act (ADA)
Jackie Stoniker, Deputy
Office of Affirmative Action Compliance
500 West Temple Street, Room 780
Los Angeles, CA 90012
Phone: (213) 202-5823
Website: : www.usdoj.gov/crtada/adahoml.htm
California Family Rights Act (CFRA)
Marie Koshkarian, HR Analyst
Department of Human Resources
500 West Temple Street, Room
Los Angeles, CA 90012
Phone: (213) 974-8404
Employee Benefits
Loretta Valenzuela, HR Analyst III
Department of Human Resources
3333 Wilshire Blvd., Suite 1000
Los Angeles, CA 90010
Phone: (213) 738-2250
CONTACTS
Employment Issues
Steve Morris, Principal Deputy County Counsel
County Counsel
500 West Temple Street, Room 648
Los Angeles, CA 90012
Phone: (213) 974-1957
"
Fair Employment and Housing Act (FEHA)
Gordon Anthony, Senior Deputy
Office of Affirmative Action Compliance
500 West Temple Street, Room 780
Los Angeles, CA 90012
Phone: (213) 202-5826
Family Medical Leave Act (FMLA)
Maria Koshkarian, HR Analyst
Department of Human Resources
500 West Temple Street, Room 585
Los Angeles, CA 90012 /
Phone: (213) 974-8404
Website: ww.dol.gov/esa/whd/fmla/
Los Angeles County Employee
Retirement Association (LACERA)
Shari Altmark, Disability Specialist
Supervisor
300 North Lake Avenue
Pasadena, CA 91101
Phone: (626) 564-6000, Ext. 4405
Loss Control and Prevention
Steve NyBlum, Assistant Division Chief
Chief Administrative Office
3333 Wilshire Blvd., Room 820
Los Angeles, CA 90010
Phone: (213) 351-5357
Long-Term Disabilty (L TD)
Cheryl Scott, Program Specialist iV
Chief Administrative Office
3333 Wilshire Blvd., Room 1000
Los Angeles, CA 90010
Phone: (213) 738-2194
Medical Provider Network (MPN)
Cathy Stein-Romo, Program Specialist II
Chief Administrative Office
3333 Wilshire Blvd., Room 1000
Los Angeles, CA 90010
Phone: (213) 351-6433
Occupational Health Programs (OHS)
Kathleen Blanchette
Chief Program Specialist
Chief Administrative Office
3333 Wilshire Blvd., Room 1000
Los Angeles, CA 90010
Phone: (213) 738-2187

Pregnancy Disabilty Leave Law (PDLL) Work Hardening
Marie Koshkarian, HR Analyst Cathy Stein-Romo, Program Specialist II
Department of Human Resources Chief Administrative Office
500 West Temple Street, Room 585 3333 Wilshire Blvd., Room 1000
Los Angeles, CA 90012 Los Angeles, CA 90012
Phone: (213) 974-8404 Phone: (213) 351-6433
Return-to-Work (RTW) Workers' Compensation
Cheryl Turkal, Program Specialist iV Alex Rossi, Chief Program Specialist
Chief Administrative Office Chief Administrative Office
3333 Wilshire Blvd., Room 1000 3333 Wilshire Blvd., Room 1000
Los Angeles, CA 90010 Los Angeles, CA 90010
Phone: (213) 738-2144 Phone: (213) 738-2154
Short-Term Disabilty (STD) Workers' Compensation
Tammy Usher, Program Specialist II Pat Wu, Assistant County Counsel
Chief Administrative Office County Counsel
3333 Wilshire Blvd., Room 1000 500 West Temple Street, Room 648
Los Angeles, CA 90010 Los Angeles, CA
Phone: (213) 738-2225 Phone: (213) 974-1928
Vocational Rehabiltation
Cheryl Turkal, Program Specialist IV
Chief Administrative Office
3333 Wilshire Blvd., Room 1000
Los Angeles, CA 90010
Phone: (213) 738-2144
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. Division of Workers' Compé
http://ww.dir.ca. qov/

LACERA - Los Angeles County Employees' Retirement Association
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WELCOME TO LACERA
Welcome to LACERA, the Los
Angeles County Employees
Retirement Association.
LACERA provides retirement, disability,
and death benefits to eligible Los Angeles
County employees and their beneficiaries.
We collect, deposit, invest, and manage
retirement funds collected from the
County, outside agencies and districts,
and County employees.
Your Contribution Rate May
Change
On Tuesday, June 21, 2005, the Los
Angeles County Board of Supervisors
approved new LACERA member
contribution rates negotiated by the
County and employee representatives.
These rates are based on actuarial
recommendations from the recent triennial
valuation. The new rates become
effective July 1, 2005. (6-21-05)
General member rates
Safety member rates
Ventura Settlement approved..
Click here to read more. (6-16-05)
Click here for information regarding
pay item treatment under the settlement.
Medicare Reimbursement for
LACERA-Sponsored Medicare
Plan Enrollees, Approved
On April 19, 2005, the Board of
Supervisors approved the County's
Medicare Part B Reimbursement Program
for calendar year 2005. As a result,
ADA - Click here to ß~ces-s-lhe j
çJ)--J)liant web site (text only ven:
Wi safe.
II's easy.
It's conveni~
My LACERA - View your persi
retirement information online
. Register on My LACERA - click t
(Active and Retired members only)
. Already_rggjs~re~? Sign in here
Click here to read the latest. (6-16-05
September 16, 2005
The theme this year is - Senior Prom
celebratory type of event. Coming u~
Look for the workshop schedule 01
and for your invitation in the mail. (
RFP
OPPORTUNITIS

. SECTION

Employee:
Deparment:
County of Los Angeles
Return to Work Program
EMPLOYEE'S REPORT OF ACCIDENT
To be completed by Employee
Employee#:
Job Title:
Accident Date: Time: I Location:
Date Reported: Accident Reported to:
Nature of fujur (e.g., strain, cut, fracture, dermatitis, multiple injuries, etc.):
Body Part fujured (e.g., head, eye, leg, back, wrist, etc. Specific left/right, etc.)
fujury Source (e.g., machinery, desk, vehicle, person, tool, stairs, ladder, etc.):
How fujury Occured (struck by..., fell from ..., exposed to ..., etc.):
Employee's Statement of What Occured:
Who witnessed the accident?
The above information is true and correct to the best of my knowledge.
Employee signature: Date:

State of California
Deparent of fudustrial Relations
DIVISION OF WORKRS' COMPENSATION
WORKERS' COMPENSATION CLAIM FORM (DWC 1)
Employee: Complete the "Employee" section and give the form to
your employer. Keep a copy and mark it "Employee's Temporary
Receipt" until you receive the signed and dated copy from your employer.
You may call the Division of Workers' Compensation and
hear recorded information at (800) 736-7401. An explanation of workers'
compensation benefits is included as the cover sheet of this form.
You should also have received a pamphlet from your employer descrbing
workers' compensation benefits and the procdures to obtain
them.
Any person who makes or causes to be made any knowingly false
or fraudulent material statement or material representation for
the purpose of obtaining 01' denying workers' compensation benefits
or payments is guilty of a felony.
Estado de California
Departamento de Relaciones Industriales
DIVISION DE COMPENSACIÓN AL TRAAJADOR
PETITION DEL EMPLEADO PARA DE COMPENSACIÓN DEL
TRAAJADOR (DWC 1)
Empleado: Complete la sección "Empleado" y entregue la forma a su
empleador. Quédese con la copia designada "Recibo Temporal del
Empleado" hasta que Ud. reciba la copiafirmada y fechada de su empleador.
Ud. puede llamar a la Division de Compensación al Trabajador al (800) 736-
7401 para oir información gravada. En la hoja cubierta de esta
forma esta la explicatión de los beneficios de compensación al trabjador.
Ud. también debería haber recibido de su empleador unfolleto describiendo los
benfcios de compensación al trabajador lesionao y los procedimientos para
obtenerlos.
Toda aquella persona que a propósito haga 0 cause que se produzca
cualquier declaración 0 representación material falsa 0 fraudulenta con el
fin de obtener 0 negar beneficios 0 pagos de compensación a trabajadores
lesionados es culpable de un crimen mayor "felonia".
Employe~omplete this section and see note above Emplead~omplete esta secccón y note la notación arrba.
1.
2.
3.
4.
5.
Name. Nombre.
Home Address, Dirección Residencial.
Today's Date. Fecha de Hoy.
City. Ciudd. State. Estado. Zip. Código Postal.
Date offujury. Fecha de la lesión (accidente). Time of fujury. Hora en que ocurrió.
Address and description of where injur happened. Dirección/lugar dónde occurió el accidente.
6. Describe injur and par of body affected. Describa la lesión y parte del cuerpo afectada.
7.
8.
Social Securty Number. Número de Seguro Social del Empleado.
Signature of employee. Firma del empleado.
Employer--omplete this section and see note below. Empleadr-complete esta sección y note la notación abajo.
9. Name of employer. ,,ombre del empleador.
10. Address. Dirección.
11. Date employer first knew of injury. Fecha en que el empleador supo por primera vez de la lesión 0 accidente.
12. Date claim form was provided to employee. Fecha en que se Ie entregó ai, empleado la petición.
13. Date employer received claim form. Fecha en que el empleado devolvió la petición al empleador.
a.m. p.m,
14. Name and address of insurance carier or adjusting agency. Nombre y dirección de la compañía de seguros 0 agencia adminstradora de seguros.
15. fusurance Policy Number. EI número de la póliza de Seguro.
16. Signature of employer representative. Firma del representante del empleador.
17. Title. Título. 18. Telephone. Teléfono.
Employer: You are required to date this form and provide copies to
your insurer or claims administrator and to the employee, dependent
or representative who fied the claim within one workin!! dav of
receipt of the form from the employee.
SIGNING THIS FORM IS NOT AN ADMISSION OF LIAILIT
o Employer copy/Copia del Ennpleador o Employee copyl Copia del Ennpleado
7/1/04 Rev.
Empleador: Se requiere que Ud.feche estaforma y que provéa copias a su compañía
de seguros, administrador de ree/amos, 0 dependientelrepresentante de ree/amas
y al empleado que hayan presentado esta petición dentro del plazo de un día
hábil desde el momenta de haber sido recibida laforma del empleado.
EL FlRMAR ESTA FORMA NO SIGNIFlCA ADMISION DE RESPONSABIUDAD
o Clais AdminsiratorlAdnninislrador de Reclannos o Temporary ReceipttRecibo del Empleado

Workers' Compensation Claim Form (DWC 1) & Notice of Potential Eligibilty
Formulario de Reclamo de Compensación para Trabajadores (DWC 1) Y Notificación de Posible Elegibilidad
If you are injured or become ill, either physically or mentally,
because of your job, including injures resulting from a workplace
crime, you may be entitled to workers' compensation benefits.
Attached is the form for fiing a workers' compensation claim with
your employer. You should read all of the information below.
Keep this sheet and all other papers for your records. You may be
eligible for some or all of the benefits listed depending on the natue
of your claim. If required you wil be notified by the claims
administrator, who is responsible for handling your claim, about your
eligibility for benefits.
To fie a claim, complete the "Employee" section of the form, keep
one copy and give the rest to your employer. Your employer will
then complete the "Employer" section, give you a dated copy, keep
one copy and send one to the claims administrator. Benefits can't
start until the claims administrator knows of the injur, so cornplete
the form as soon as possible.
Medical Care: Your claims administrator wil pay all reasonable and
necessary medical care for your work injur or illness. Medical
benefits may include treatment by a doctor, hospital services,
physical therapy, lab tests, x-rays, and medicines. Your claims
administrator will pay the costs directly so you should never see a
bilL. For injures occurrng on or after 1/1/04, there is a limit on
some medical services.
The Primary Treatinl! Physician æTP) is the doctor with the
overall responsibility for treatment of your injur or ilness.
Generally your employer selects the PTP you wil see for the first 30
days, however, in specified conditions, you may be treated by your
predesignated doctor. If a doctor says you still need treatment after
30 days, you may be able to switch to the doctor of your choice.
Special rules apply if your employer offers a Health Care
Organization (HCO) or after 1/1/05, has a medical provider network.
Contact your employer for more information. If your employer has
not put up a poster describing your rights to workers' compensation,
you may choose your own doctor inuediately.
Within one working day after an employee fies a claim form, the
employer shall authorie the provision of all treatment, consistent
with the applicable treating guidelines, for the alleged injur and
shall continue to provide treatment until the date that liability for the
claim is accepted or rejected. Until the date the claim is accepted or
rejected, liability for medical treatment shall be limited to ten
thousand dollars ($10,000).
Disclosure of Medical Records: After you make a claim for
workers' compensation benefits, your medical records wil not have
the same privacy that you usually expect. If you don't agree to
voluntarly release medical records, a workers' compensation judge
may decide what records wil be released. If you request privacy, the
judge may "seal" (keep private) certain medical records.
Payment for Temporarv Disabiltv (Lost Wal!es): If you can't
work while you are recovering from a job injury or ilness, you wil
receive temporary disability payments. These payments may change
or stop when your doctor says you are able to return to work. These
benefits are tax-free. Temporary disability payments are two-thirds of
your average weekly pay, within minimums and maximums set by
state law. Payments are not made for the first three days you are off
the job unless you are hospitalized overnight or cannot work for more
than 14 days.
Si Ud. se lesiona 0 se enferma, ya sea fisica 0 rnentalmente, debido a su
trabajo, incluyendo lesiones que resulten de un crimen en ellugar de trabajo,
es posible que Ud. tenga derecho a beneficios de compensación para
trabajadores. Se adjunta el formulario para presentar un reclamo de
compensación para trabajadores con su empleador. Ud. debe leer toda la
información a continuación. Guarde esta hoja y todos los demás
documentos para sus archivos. Es posible que usted reúoa los requisitos
para todos los beneficios, 0 parte de éstos, que se enumeran, dependiendo de
la indole de su reclamo. Si se requiere, ellla administrador(a) de reclamos,
quien es responsable del manejo de su reclamo, Ie notificará a usted, 10
referente a su elegibilidad para beneficios.
Para presentar un reclamo, complete la sección del formulario designada
para el "Empleado", guarde una copia, y déle el resto a su empleador.
Entonces, su empleador cornpletará la sección designada para el
"Empleador", Ie dará a Ud. una copia fechada, guardará una copia, y enviará
una alia la administrador(a) de reclamos. Los beneficios no pueden
comeozar hasta, que el/a administrador(a) de reclamos se entere de la
lesión, asÍ que complete el formulario 10 antes posible.
Atención Médica: Su administrador(a) de reclamos pagará toda la atención
médica razonable y necesaria, para su lesión 0 enfermedad relacionada con
el trabajo. Es posible que los beneficios médicos incluyan el tratamiento por
parte de un médico, los servicios de hospital, la terapia fisica, los análisis de
laboratorio y las medicinas. Su admnistrador(a) de reclamos pagará
directamente los costos, de rnanera que usted nunca verá un cobro. Para
lesiones que ocuren en 0 después de 1/1/04, hay un limite de visitas para
ciertos servicios médicos.
El Médico Primario Que le Atiende-Primarv Treatine Phvsician PTP es
el médico con toda la responsabilidad para dar el tratamiento para su lesión
o enfermedad. Generalmente, su empleador selecciona al PTP que Ud. verá
durante los primeros 30 dias. Sin embargo, en condiciones específicas, es
posible que usted pueda ser tratado por su médico pre-designado. Si el
doctor dice que usted aúo necesita tratammento después de 30 dias, es posible
que Ud. pueda cambiar al médico de su preferencia. Hay reglas especiales
que son aplicables cuando su empleador ofrece una Organización del
Cuidado Médico (HCO) 0 depués de 1/1/05 tiene un Sistema de Proveedores
de Atención Médica. Hable con su empleador para más información. Si su
empleador no ha colocado un poster describiendo sus derechos para la
compensación para trabajadores, Ud. puede seleccionar a su propio médico
inmediatamente.
El empleador autorizará todo tratamiento médico consistente con las
directivas de tratamiento applicables a la lesión 0 enfermedad, durante el
primer dÍa laboral después que el empleado efectúa un reclamo para
beneficios de compensación, y continuará proveyendo este tratamiento hasta
la fecha en que el reclamo sea aceptado 0 rechazado. Hasta la fecha en que
el reclamo sea aceptado 0 rechazado, el tratamiento médico será limitado a
diez mil dólares ($10,000).
Divull!ación de Expedientes Médicos: Después de que Ud. presente un
reclamo para beneficios de compensación para los trabajadores, sus
expedientes médicos no tendrán la misma privacidad que usted normalmente
espera. Si Ud. no está de acuerdo en divulgar voluntariamente los
expedientes médicos, un(a) juez de compensación para trabajadores
posiblemente decida qué expedientes se revelarán. Si Ud. solicita
privacidad, es posible que el/la juez "selle" (mantenga privados) ciertos
expedientes médicos.
Pal!o por Incapacidad Temporal (Sueldos Perdidos): Si Ud. no puede
trabajar, mientras se está recuperando de una lesión 0 enfermedad
relacionada con el trabajo, Ud. recibirá pagos por incapacidad temporaL. Es
posible que estos pagos cambien 0 paren, cuando su médico diga que Ud.
está en condiciones de regresar a trabajar. Estos beneficios son libres de

Workers' Compensation Claim Form (DWC 1) & Notice of Potential Eligibilty
Formulario de Reclamo de Compensación para Trabajadores (DWC 1) y Notìficación de Posible Elegibilidad
Return to Work: To help you to retu to work as soon as possible,
you should actively communicate with your treating doctor, claims
administrator, and employer about the kinds of work you can do
while recovering. They may coordinate efforts to return you to
modified duty or other work that is medically appropriate. This
modified or other duty may be temporary or may be extended
depending on the nature of your injury or illness.
Pavment for Permanent Disabiltv: If a doctor says your injury or
ilness results in a permanent disability, you may receive additional
payments. The amount will depend on the tye of injury, your age,
occupation, and date of injury.
Vocational Rehabiltation (V): If a doctor says your injury or
illness prevents you from returning to the same tye of job and your
employer doesn't offer modified or alternative work, you may
qualify for VR. If you qualify, your claims administrator wil pay the
costs, up to a maximum set by state law. VR is a benefit for injuries
that occurred prior to 2004.
Supplemental Job Displacement Benefi (SJDß): If you do not
retu to work within 60 days after your temporary disability ends,
and your employer does not offer modified or alternative work, you
may qualify for a nontransferable voucher payable to a school for
retraining and/or skil enhancement. If you qualify, the claims
administrator wil pay the costs up to the maximum set by state law
based on your percentage of permanent disability. 5mB is a benefit
for injuries occurng on or after 1/1/04.
Death Benefits: If the injur or illness causes death, payments may
be made to relatives or household members who were financially
dependent on the deceased worker.
It is iUel!al for your emplover to punish or fire you for having a job
injury or ilmess, for filing a claim, or testifying in another person's
workers' compensation case (Labor Code 132a). If proven, you may
receive lost wages, job reinstatement, increased benefits, and costs
and expenses up to limits set by the state.
You have the right to disagree with decisions affecting your claim. If
you have a disagreement, contact your claims administrator first to
see if you can resolve it. If you are not receiving benefits~ you may
be able to get State Disability Insurance (SOl) benefits. Call State
Employment Development Deparent at (800) 480-3287.
You can obtain free information from an information and assistance
officer of the State Division of Workers' Compensation, or you can
hear recorded information and a list of local offices by callng (800)
736-7401. You may also go to the DWC web site at ww.dir.ca.l!ov.
Link to Workers' Compensation.
You can consult with an attornev. Most attorneys offer one free
consultation. If you decide to hire an attorney, his or her fee wil be
taken out of some of your benefits. For names of workers'
compensation attorneys, call the State Bar of California at (415) 538-
2120 or go to their web site at ww.californiaspecialist.orl!.
impuestos. Los pagos por incapacidad temporal son dos tercios de su pago
semanal promedio, con cantidades mínimas y máximas establecidas por las
leyes estatales. Los pagos no se hacen durante los primeros tres días en que
Ud. no trabaje, a menos que Ud. sea hospitalizado(a) de noche, 0 no pueda
trabajar durante más de 14 días.
Rel!reso al Trahaio: Para ayudarle a regresar a trabajar 10 antes posible,
Ud. debe comunicarse de manera activa con el médico que Ie atienda, el/la
admnistrador(a) de reclamos y el empleador, con respecto alas clases de
trabajo que Ud. puede hacer mientras se recupera. Es posible que ellos
coordinen esfuerzos para regresarle a un trabajo modificado, 0 a otro trabajo,
que sea apropiado desde el punto de vista médico. Este trabajo modificado,
u otro trabajo, podna extenderse 0 no temporalmente, dependiendo de la
índole de su lesión 0 enfermedad.
Pal!o por Incapacidad Permanente: Si el doctor dice que su lesión 0
enfermedad resulta en una incapacidad permanente, es posible que Ud.
reciba pagos adicionales. La cantidad dependerá de la clase de lesión, su
edad, su ocupación y la fecha de la lesión.
Rehahiltación Vocacional: Si el doctor dice que su lesión 0 enfermedad no
Ie permte regresar a la misma clase de trabajo, y su empleador no Ie ofrece
trabajo modificado 0 alterno, es posible que usted reúna los requisitos para
rehabilitación vocacional. Si Ud. reúne los requisitos, su administrador(a)
de reclamos pagará los costos, hasta un máximo establecido por las leyes
estatales. Este es un beneficio para 1esiones que ocureron antes de 2004.
Beneficio Suplementario por Desplazamiento de Trabaio: Si Ud. no
vuelve al trabajo en un plazo de 60 días después que los pagos por
incapcidad temporal terminan, y su empleador no ofrece un trabajo
modificado 0 alterno, es posible que usted reúne los requisitos para recibir
un vale no-transferible pagadero a una escuela para recibir un nuevo
entrenamiento y/o mejorar su habilidad. Si Ud. reúne los requisitios, el
admnistrador(a) de reclamos pagará los costos hasta un máximo establecido
por las leyes estatales basado en su porcentaje del incapicidad permanente.
Este es un beneficio para lesiones que ocurren en 0 después de 1/1/04.
Beneficios no Muerte: Si la lesión 0 enfermedad causa la muerte, es
posible que los pagos se hagan a los parentes 0 a las personas que vivan en
el hogar, que dependían económicamente del/de la trabajador(a) difuto(a).
Es ilel!al Que su empleador Ie castigue 0 despida, por sufrr una lesión 0
enfermedad en el trabajo, por presentar un reclamo 0 por atestiguar en el
caso de compensación para trabajadores de otra persona. (El Codigo Laboral
sección 132a). Si es probado, puede ser que usted reciba pagos por perdida
de sueldos, reposición del trabajo, aurento de beneficios, y gastos hasta un
limite establecido por el estado.
Ud. tiene derecho a estar en desacuerdo con las decisiones que
afecten su reclamo. Si Ud. tiene un desacuerdo, primero comuníquese con
su administrador(a) de reclamos, para ver si usted puede resolverlo. Si usted
no está recibiendo beneficios, es posible que Ud. pueda obtener beneficios
de Seguro Estatal de Incapacidad (SOL). Uame al Departamento Estatal del
Desarrollo del Empleo (EDD) al (800) 480-3287.
Ud. puede obtener información gratis, de un oficial de información
y asistencia, de la División estatal de Compensación al Trabajador (Division
of Workers' Compensation - D We), 0 puede escuchar información grabada,
así como una lista de oficinas locales, lIamando al (800) 736-7401. Ud.
tabién puede ir al sitio electrónico en el Internet de la DWC en
ww.dir.ca.l!ov. Enlácese a la sección de Compensación para Trabajadores.
Ud. puede consultar con un(a) ahol!ado(a). La mayona de los abogados
ofrecen una consulta gratis. Si Ud. decide contratar a un(a) abogado(a), sus
honorarios se tomarán de sus beneficios. Para obtener nombres de abogados
de compensación para trabajadores, lIame a la Asociación Estatal de
Abogados de California (State Bar) al (415) 538-2120, ó vaya a su sitio
electrónico en el Internet en ww.californiaspecialist.orl!.

c
EMPLOYER'S REPORT OF
OCCUPATIONAL INJURY OR ILLNESS
e;se comp e e in np IC; e
Any person who makes or causes to be made any
knowingly false or fraudulent materi;1 sttement or
m;terial representation for the purpose of obtaIning or
denying workers compens;tlon benerit or p;yments is
guilty 01 a lelony.
OSHA CASE NO.
FATALITY
California law requires employers to report within five days of knowledge every occupational injury or illness which results in lost time beyond the
date of the incident OR requires medical treatment beyond first aid. If an employee subsequently dies as a result of a previously reported injury or
ilness, the employer must file within five days of knowledge an amended report indicating death. In addition, every serious injury, ilness, or death
must be reported immediately by telephone or telegraph to the nearest offce of the California Division of Occpational Safety and Health.
1. FIRM NAME la. Employee No.
E 2. MALING ADDRESS: (Number, Street, City, Zip)
M
P
L 3. LOCATION II diferent lrom Mailng Address (Number, Street, City and Zip)
o
Y
E 4. NATURE OF BUSINESS; e.g.. Painting conlractor, wholesale grocer, sawmil, hotel, etc.
R
I
&. TYPE OF EMPLOYER: D D D
Private Slate County
7. DATE OF INJURY I ONSET OF ILLESS 8. TIME INJURynLLNESS OCCURRED
(mmlddly)
PM
11. UNABLE TO WORK FOR ATLEAST DNE 12. DATE LAST WORKED (mmlddl)
FULL DAY AFT~ OF INJURY?
DYes UNO
15. PAID FULL DAYS WAGES FOR DATE OF 1&. SALARY BEING CONTINUED?
NJURYOR LASTO 0 rïes DNO
DAY WORKD? Yes No L.'
Dily DSChooDDstrict
5. TIME EMPLOYEE BEGAN WORK
PM
2a. Phone Number
3a. Departent No.
6. St;te unemployment Insurance acct.no
DOter Gov'~ Specif
10.IF EMPLOYEE DIED, DATE OF DEATH (mm/dd/y)
13. DATE RETURNED TO WORK (mmlddly) 14. IF STILL OFÕ CHECK THIS BOX:
17. DATE OF EMPLOYER'S KNOWLEDGE /NOTICE OF 18. DATE EMPLOYEE WAS PROVIDED CLAIM FORM
INJURynLLNESS (mmlddly) FORM (mmlddlyy)
IS. SPECIFIC INJURynLLESS AND PART OF BODY AFFECTEO, MEDICAL DIAGNOSIS IIlValiable, o.g.. Second degree burns on righlarm, tedonllI on lef elbow,lead poisoning
~ 20. LOCATION WHERE EVENT OR EXPOSURE OCCURRED (Number, SIr..~ City, Zip)
U
R
Y 22. DEPARTMENT WHERE EVENT OR EXPOSURE OCCURRED, e.g.. Shipping deparlen~ machine shop.
20a. COUNTY 21. ON EMPLOYER'S PREMISES?
DYes DNa
3. Oter Workers Injured or ii In llti~
DYes L.No
24. EQUIPMENT, MATERIALS AND CHEMICALS THE EMPLOYEE WAS USING WHEN EVENT OR EXPOSURE OCCURRED, e.g.. Acetlene, welding torch, lann tractor, scaffold
o
R
25. SPECIFIC ACTITY THE EMPLOYEE WAS PERFORMING WHEN EVENT OR EXPOSURE OCCURRD, e.g.. Welding seams of melll lonns, loading boxes onto truck.
I
L
L 2&. HOW INJURynLLESS OCCURRD. DESCRIBE SEQUENCE OF EVENTS. SPECIFY OBJECT OR EXPOSURE WHICH DIRECT1Y PRODUCED THE INJURYIILLESS, o.g.. Worker steppe back to Inspe work
N and slippe on scrap materiL. As he tel~ he brushe agalnsttresh weld, and burned right hand. USE SEPARTE SHEET IF NECESSARY
E
S
S
- hours per dayi - days per week, - tolll weekly hours
38. GROSS WAGESISALARY
Completed By (type or print) Signature & Tltl..
$
per
37a. EMPLOYMENT STATUS
. PARTICIPANT?
Oregular,lull.time o part-tme
Dtemporary Dsoasonal DYes DNO
DYes 0 No
35. OTHER PAYMENTS NOT REPORTE AS WAGESISALRY (e.g. tips, meals, overtme, bonuses, et.)?
FORM 5020 (Rev7) June 2002 FILING OF THIS FORM IS NOT AN ADMISSION OF LIABILITY
o
Please do not use
this column
CASE NUMBER
OWNERSHIP
INDUSTRY
OCCUPATION
SEX
AGE
DAILY HOURS
DAYS PER WEEK
WEEKLY HOURS
WEEKLY WAGE
COUNTY
NATURE OF INJURY
PART OF BODY
SOURCE
EVENT
SECONDARY SOURCE
EXTENT OF INJURY
Date (mm/ddlyy)
. Confdential Information may be disclosed only to the empl yee, former employee, Dr their personal representative lCCR Title 814300.35)1 to others for the purpose of processing a workers' compensation Dr other Insurance
federal workplaco safety agencies.

County of Los Angeles
Employee's Statement Declining Medical Treatment
Employee's Name Department
Although I have been offered ofirst-aid omedical treatment ¡advice,
in connection with my injury, I am declining the offer for the following
reason(s):
Signed- Supervisor or Other
County Official
csr:g:DeclMedTrtnn04. word
Signed- Employee Date

FIRST ALERT
Notice of Possible Industrial Injury or Illness
Date
FAX TO:
Attn:
FROM:
Fax Number
Return to Work Coordinator
Supervisor (Print Name) Ext.
Department
Employee(Print Name)
Employee Number
Basic Description of Injury
.
Date Injury Occurred

Name:
Claim Number:
Employee Number:
Date of Injury:
LDW/RTW VERIFICATION FORM
This form should be filled and returned to the Workers' Compensation TPA.
The dates used on this form wiH be used to complete the benefit notice.
Please make sure the dates are accurate. Complete for each date
since the date of injury that the employee has been off work.
(Attach a separate sheet if additional room is needed).
Last Date Worked:
Returned to Work:
Last Date Worked:
Returned to Work:
Last Date Worked:
Returned to Work:
Last Date Worked:
Returned to Work:
Authorized Departmental Rep Phone Date

County of Los Angeles
Return to Work Program
PATIENT STATUS REPORT: Physical Injury
To be completed by Physician
Employee Name: Emp.#
Claim Number: Date of Injur:
Thrd Pary Administrator: Date of Visit:
o "Yes, I have reviewed the employee's Job Description prior to completing work status information."
(physician, please check box.)
WORK STATUS
Check appropriate box and enter date
0 Released to Usual and Customar Position WITHOUT 0 Expected Release to Usual and Customar Position on:
Limitations on:
0 Released to Light Duty Assignment with the Work 0 Expected Release to Light Duty Assignent on:
Restrctions listed below on:
0 Totally Temporarly Disabled until: 0 Released from Care on:
RECOVERY LIMITA TIONS/WORK RESTRICTIONS
Check If
Indicate limitations related to the following activites: No
Limitation
s
Sitting: Max. 2 hrs. 4hrs. 6 hrs. per day Other/notes:
Standing: Max. _2 hrs. _4 hrs. _6 hrs. per day Other/notes:
Walking: Max. _2 hrs. _4 hrs. _6 hrs. per day Other/notes:
Liftng/Caring:
Employee can liftcar up to - pounds infrequently.
Employee can liftcar up to pounds occasionally.
Employee can liftcar up to - pounds frequently.
Employee canot liftcar more than - pounds.
Bending:
Squatting:
Kneeling/Crawling:
Climbing:
Reaching:
Pushing/llng:
Gripping/Grasping:
Repetitive Hand Use:
Fine Finger Manipulation:
Other:
Can employee have contact with the public? DYes o No.
0 Follow Up Appointment On:
0 Medication:
0 Physical Therapy: - time(s) per week for - weeks
Physician's Signature:
Physician's Name:
TREATMENT PLAN
Date:
Phone Number: Fax Number:

This packet should be given to the employee
County of Los Angeles
Return to Work Program
, RECEIPT OF EMPLOYEE PACKET
when a potential 'work related accident
or injury has been reported, but the employee refuses to complete the forms at the
time of reporting. By signing in the spaces below, :!the employee and supervisor
acknowledge that the employee has received the Employee Packet for use
throughout the course of this workers' compensation claim. This packet is a key
component of the County of Los Angeles Return to Work Program and should be
completed in a timely manner. It provides the employee with critical information
regarding the filing of an industrial injury.
The Supervisor should retain this document in the employee's file.
Employee's Signature Print Name
Supervisor's Signature Print Name
, . ~.. .
Date
Date

Date
County of Los Angeles
Return to Work Program
TREA TMENT REFERRL SLIP
To be completed by Supervisor
Doctor/Medical Facility:
Address:
Phone: I Fax:
This form authorizes you to administer initial treatment to the following employee who has reported
an injury which may be work related.
Employee Name: I Emp.#:
Date of fujury: I Job Title:
Deparment Name and Number:
Employee's Work Address:
Workers' Compensation Thid Pary Administrator:
TP A Address:
Employee Supervisor:
Return To Work Coordinator:
I Phone:
Phone:
Phone:
INSTRUCTIONS TO MEDICAL PROVIDER
1. Complete Patient Status Report and give to Employee to return to Supervisor.
2. Send the original completed Doctor's First Report of fujury to the Thid Pary Administrator listed
above.
3. Fax a copy of the completed Doctor's First Report of fujur to
mail to , CA
at_-_-_or
4. Call the Third Party Administrator at the number listed above immediately to request any of the
following durng the initial visit: Consultation
Hospitalization
Additional Diagnostic Testing
Physical Therapy
5. Call at ----- if you have any questions.
6. Send all Medical Bils to the Third Party Administrator listed above.

(date)
To: Initial Treatment Physician
Re: Injured Worker:
(Print name of Employee)
County of Los Angeles
Return to Work Program
TREA TING PHYSICIAN'S LETTER: Physical Injury
. Our employee has been sent to your offce for medical treatment of an injury that may be
work-related.
. Enclosed is the job description of the injured worker's duties. We would request that a
review of hislher job description be made prior to making a decision regarding recovery
limitations/work restrictions.
. The County of Los Angeles has a Return-to-Work Program and wil attempt to modify
the current position or place an injured worker into a Work Hardeninglight Duty
Assignment. If you have any questions call at
. Please use the enclosed Patient Status Report to outlne the recovery limitations/work
restrictions, if any, recommended at this time, as well as the treatment plan.
. All treatment is pursuant to ACOEM Guidelines, and must comply with DWC
Regulations.
. Payment is according to fee schedule pursuant to Labor Code section 5307.1 and 8
California Code Regulation 9789.10.
. Reporting must adhere to the requirements of the Division of Workers' Compensation.
Should you have any questions or need to review additional infonnation regarding our program, please
contact the Los Angeles County Chief Admnistrative Office (CAO) Disability Administration at (213)
351-6433.
Thank you for your full cooperation.
The Patient Status Report needs to be completed prior to the employee
leaving your offce.

TO:
FROM:
DATE:
WAGE STATEMENT - MONTHLY & SALARIED EMPLOYEES
Name:
Employee #:
Date of Injury:
The workers' compensation TPA needs the wage information for 13 months of wage information.
For example, if the date of injury is in March you would provide wage information from March of the
following year up to March of the current year.
BASE SALARY FLEX
MONTH/YEAR (DO NOT
DEDUCT FOR
TIME OFF)
EARNINGS
(TAXABLE
CASH)
BONUS PAY
(SPECIFY
TYPE)
Authorized Deparmental Representative Phone Date
OVERTIME

DATE:
To:
From
WAGE STATEMENT - DAILY AND HOURLY EMPLOYEES
Employee:
Employee #:
Date of Injury:
The workers' compensation TP A needs the wage information for 13 months of wage
information. For example, if the date of injury is in March you would provide wage
information from March of the following year up to March of the current year.
GROSS PAY
MONTHNEAR TOTAL HOURS (INCLUDING OVERTIME
WORKED AND BONUS PAY)
Authorized Departmental Representative Phone Number Date

County of Los Angeles
Return to Work Program
WEEKLY TELEPHONE CALL VERIFICATION SHEET
For use when employee is Totally Temporarly Disabled
This form is to be used by the Supervisor as a worksheet to document weekly telephone contact
with Employee. Supervisor wil call Employee each week at a pre-arranged time. Employee can
advise Supervisor of medical status, future doctor appointments, and the general progress of
recovery.
Employee Name: Date of Injury:
Treating Physician: Supervisor:
Week 1
Week 2
Week 3
Week 4
Week 5
Week 6
Week 7
Week 8
Week 9
Week 10
Week 11
Week 12
Day of the Week:
Agreed Schedule of Weekly Calls
I
Time:
Date of Continuing Total Est. Date of Date of Next
Telephone Date of Last Disability? Est. Date of Retur to Work Scheduled
Call Doctor Visit (Yes or No) Retur to U&C Hardening Doctor Visit

(Your Dept. Name Here)
COUNTY OF LOS ANGELES
WORK HARDENING TRANSITIONAL ASSIGNMENT AGREEMENT
Employee : Title:
_____________________________
Employee No. :___________________ Today’s Date: __________________
Claim #:______________________________
Date of Injury: Facility: Dept. # : ______
Pay Location # ______
Dr. has released me to return to work with the following
recovery limitations/work restrictions:
.
In an effort to assist you in returning to full duty, we have identified a temporary work hardening
assignment that is compatible with your limitations (duties listed on back of this form). Your
placement on this temporary assignment is intended to prevent further injury or aggravation to
your present condition. You must agree that you will work within your treating physician=s
recovery limitations/work restrictions. Also, if given any duties outside these limitations, you will
immediately notify your supervisor in writing. If you refuse this temporary work hardening
transitional assignment, you may lose your entitlement to Workers= Compensation disability
benefits.
The total length of your Work Hardening Transitional Assignment should last no longer than 12
weeks beginning with the date listed below. If, at the conclusion of your Work Hardening
Assignment, it has been medically determined that you are unable to return to your usual and
customary job, an interactive process will be conducted with you to determine a possible future
assignment.
Total Length of Work Hardening Transitional Assignment: _________ to _________
Start Date End Date
(If the End Date changes in the future, prepare and email the “Amended” WHTAA
form to appropriate CAO staff.)
NOTE TO SUPERVISOR: Please review with the injured worker their recovery limitations and
Work Hardening Transitional Assignment before signing. Complete and return signed original
to your Department’s Return-To-Work Coordinator.
Employee Signature Print Name Date
Supervisor Signature Print Name Date
(Side I)

(Your Dept. Name Here)
COUNTY OF LOS ANGELES
WORK HARDENING TRANSITIONAL ASSIGNMENT AGREEMENT
The duties for the temporary work hardening transitional assignment referenced on Side 1 of
this form are as follows:
(Side 2)

(Your Dept. Name Here)
COUNTY OF LOS ANGELES
WORK HARDENING TRANSITIONAL ASSIGNMENT AGREEMENT
"AMENDED"
What is
Amended:
Date: Initials:
Employee: Title:
Employee No.: Today'sDate:
Claim#:
Date of Injury: Facility: Dept. #:
Pay Location #
Dr. has released me to retum to work with the following
recovery limitations/work restrictions:
In an effort to assist you in retuming to full duty, we have identified a temporary work hardening
assignment that is compatible with your limitations (duties listed on back of this form). Your
placement on this temporary assignment is intended to prevent further injury or aggravation to
your present condition. You must agree that you will work within your treating physician's
recovery limitations/work restrictions. Also, if given any duties outside these limitations, you will
immediately notify your supervisor in writing. If you refuse this temporary work hardening
transitional assignment, you may lose your entitlement to Workers' Compensation disability
benefis. .
The total length of your Work Hardening Transitional Assignment should last no longer than 12
weeks beginning with the date listed below. If, at the conclusion of your Work Hardening
Assignment, it has been medically determined that you are unable to return to your usual and
customary job, an interactive process wil be conducted with you to determine a possible future
assignment.
Total Length of Work Hardening Transitional Assignment:
Start Date
to End Date
NOTE TO SUPERVISOR: Please review with the injured worker their recovery limitations and
Work Hardening Transitional Assignment before signing. Complete and return signed original
to the Retum-To-Work offce and fax to ( )
Employee Signature
Supervisor Signature
Csr:g:ERTWHAAmended.word
Print Name Date
Print Name Date

DWC-AD 10133.53 NOTICE OF OFFER OF MODIFIED OR ALTERNATIVE WORK
For injuries occurring on or after 1/1/04
THIS SECTION COMPLETED BY CLAIMS ADMINISTRATOR:
Employer (name of firm)
(name of job)
You may contact
Date of offer:
Claims Administrator:
NOTICE TO EMPLOYEE Name of employee:
Date job starts:
is offering you the position of a
concerning this offer. Phone No.:
Date of Injury: Date offer received:
Claim Number:
You have 30 calendar days from receipt to accept or reject the attached offer of modified or alternative work.
Regardless of whether you accept or reject this offer, the remainder of your permanent disabilty payments may
be decreased by 15%. However, if you fail to respond in 30 days or reject this job offer, you wil not be entitled
to the supplemental job displacement benefit unless:
Modified Work D or Alternative Work D
A. You cannot perform the essential functions of the job; or
B. The job is not a regular position lasting at least 12 months; or
C. Wages and compensation offered are less than 85% paid at the time of injury; or
D. The job is beyond a reasonable commuting distance from residence at time of injury.
THIS SECTION TO BE COMPLETED BY EMPLOYEE
- 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
i feel i cannot accept this offer because:
NOTICE TO THE PARTIES
If the offer is not accepted or rejected within 30 days of the offer, the offer is deemed to be rejected by the employee.
The employer or claims administrator must forward a completed copy of this agreement to the Administrative Director within 30 days
of acceptance or rejection. (A.D., "SJDB," Division of Workers' Compensation, P.O. Box 420603, SF, CA 94102-3660)
If a dispute occurs regarding the above offer or agreement, either party may request the Administrative Director to resolve the dispute
by filing a Request for Dispute Resolution (Form DWC-AD 10133.55) with the Administrative Director.
Date
MANDATORY FORM (Page 1 of 2)
STATE OF CALIFORNIA
(08/05)

DWC-AD 10133.53 NOTICE OF OFFER OF MODIFIED OR ALTERNATIVE WORK
For injuries occurring on or after 1/1/04
POSITION REQUIREMENTS
Actual job title:
Waqes: $ per
- -
Hour Week Month
Is salary of modified/alternative work the same as pre-injury job? Yes No
- -
Is salary of modified/alternative work at least 85% of pre-injury Yes No
job?
- -
Wil job last at least 12 months? Yes
- -
No
Is the job a regular position required by the employer's business? Yes No
Work
location:
Name of doctor who approved job restrictions (optional):
report: :
Date of last a ment of Tern ora Total Disabili :
Pre arer's Name:
Preparer's Si nature: Date
Date of
MANDATORY FORM (Page 2 of 2)
STATE OF CALIFORNIA
(08/05)

- DWC-AD 10133.55 Has
- -
employer accepted this claim? DWC Use Only
Yes No
Request for Dispute Resolution Has liabilty
- -
for injury been -found by the WCAB?
Before the Administrative Yes No
Has it been more than 60 days since TTD ended?
Director
Yes No
(For injuries occurring on or after Has PPD award been stipulated, issued/approved?
1/1/04) -Yes -No
_Original _Response
Social Security Number
I WCAB Number I DWC Unit Number
Employee Name (Last) (First) (M!) Phone Date of Birth
Address (Street) (City) (State) (Zip)
Empioyer Name Phone Insurance Company Name; Or, if Self.lnsured, Certificate Name
Address Adjusting Agency Name (if adjusted)
City, State, Zip Claims Mailng Address
Date of Injury
City, State, Zip Phone No.
I Claim Number
Employee Representative (if any) Employer Representative
Firm Name Firm Name
Address Address
City, State, Zip Phone No. City, State, Zip Phone No.
Vocational & Return to Work Counselor (if applicable)
Firm Name Representative Name
Address (Street, City, State, Zip Phone No.
The Administrative Director is requested to resolve the following dispute because the parties disagree on: (Please describe and attach all pertinent
documents)
Summary of Parties' Informal Effort to Resolve this Dispute Proof of Service: I declare under penalty of pe~ury under the laws of the
State of California that on the date written below, I mailed a copy of this
request with a copy of any documents included with this request to the
following parties at the following addresses:
Administrative Director, (SJDB), Division of Workers' Compensation,
P.O. Box 420603, San Francisco, CA 94102-3660
Name of Requester Date Signature Date
(Mandatory Form DWC-AD 10133.55 08/05)

NOTICE OF OFFER OF MODIFIED OR ALTERNATIVE WORK
THIS SECTION COMPLETED BY EMPLOYER OR CLAIMS ADMINISTRATOR:
Employer (name of firm)
(name of job)
Attach a list of the duties required of the position.
You may contact concerning this offer.
Date of offer: Date job starts:
is offering you the position of a
Phone No.:
Claims Administrator: Claim Number:
NOTICE TO EMPLOYEE Name of employee:
Date offer received:
You have 30 calendar days from receipt to accept or reject this offer of modified or alternative work. If you reject this job
offer, you wil not be entitled to rehabilitation services unless:
Modified Work
A. The proposed modification(s) to accommodate required work restrictions are inadequate.
B. The modified job wil not last 12 months.
Alternative Work
A. You cannot perform the essential functions of the job; or
B. The job is not a regular position lasting at least 12 months; or
C. Wages and compensation offered were less than 85% paid at the time of injury; or
D. The job is beyond a reasonable commuting distance from residence at time of injury.
THIS SECTION TO BE COMPLETED BY EMPLOYEE
D i accept this offer of Modified or Alternative work.
D i reject this offer of Modified or Alternative work and understand that i am not entitled to vocational rehabilitation services.
Signature
i feel I cannot accept this offer because:
NOTICE TO THE PARTIES
If the offer is not accepted or rejected within 30 days of the offer, the offer is deemed to be rejected by the employee.
The employer or claims administrator must forward a completed copy of this agreement to the Rehabilitation Unit with a Notice of
Termination (OWC Form RU-105) within 30 days of acceptance or rejection.
If a dispute occurs regarding the above offer or agreement, either part may request the Rehabilitation Unit to resolve the dispute by
filing a Request for Dispute Resolution (OWC Form RU-103) at the applicable Rehabiltation Unit. The Rehabilitation Unit venue is
the same as the Workers' Compensation Appeals Board. If no WCAB case exists, fie with a Rehabilitation Unit at the appropriate
district offce.
Date
MANDATORY FORMAT
STATE OF CALIFORNIA
OWC-RU-94 (01/03) §10133.12

DWC-AD 10133.53 NOTICE OF OFFER OF MODIFIED OR ALTERNATIVE WORK
For injuries occurring on or after 1/1/04
THIS SECTION COMPLETED BY CLAIMS ADMINISTRATOR:
Employer (name of firm) ________ is offering you the position of a
(name of job) _ ________________________________________.
You may contact _ _________concerning this offer. Phone No.: _ _____
Date of offer: _ _________ Date job starts: _ _________________
Claims Administrator: _ ______________ Claim Number: _ _____
NOTICE TO EMPLOYEE Name of employee: _ _______
Date of injury: _ ____ Date offer received: _ ___
You have 30 calendar days from receipt to accept or reject the attached offer of modified or alternative work.
Regardless of whether you accept or reject this offer, the remainder of your permanent disability payments
may be decreased by 15%. However, if you fail to respond in 30 days or reject this job offer, you will not be
entitled to the supplemental job displacement benefit unless:
Modified Work or Alternative Work
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.
A. You cannot perform the essential functions of the job, or
B. The job is not a regular position lasting at least 12 months, or
C. Wages and compensation offered are less than 85% paid at the time of injury; or
D. The job is beyond a reasonable commuting distance from residence at time of injury.
THIS SECTION TO BE COMPLETED BY EMPLOYEE
___ 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.
I feel I cannot accept this offer because:
__________________________________ Date _____________________
Signature
NOTICE TO THE PARTIES
If the offer is not accepted or rejected within 30 days of the offer, the offer is deemed to be rejected by the employee.
The employer or claims administrator must forward a completed copy of this agreement to the Administrative Director within 30 days
of acceptance or rejection. (A.D., “SJDB,” Division of Workers’ Compensation, P. O. Box 420603, S. F., CA 94142-0603).
If a dispute occurs regarding the above offer or agreement, either party may request the Administrative Director to resolve the
dispute by filing a Request for Dispute Resolution (Form DWC-AD 10133.55) with the Administrative Director.
MANDATORY FORM (Page 1 of 3)
STATE OF CALIFORNIA
(08/06)

DWC-AD 10133.53 NOTICE OF OFFER OF MODIFIED OR ALTERNATIVE WORK
For injuries occurring on or after 1/1/04
POSITION REQUIREMENTS
Actual job title:
Wages: $ per Hour Week Month
Is salary of modified/alternative work the same as pre-injury job? Yes No
Is salary of modified/alternative work at least 85% of pre-injury job? Yes No
Will job last at least 12 months? Yes No
Is the job a regular position required by the employer’s business? Yes No
Work
Location: _ _____________
Duties required of the position:
Description of activities to be performed (if not stated in job description):
Physical requirements for performing work activities (include modifications to usual and customary job):
Name of doctor who approved job restrictions (optional): _ ________
Date of report: _ ____
Date of last payment of Temporary Total Disability:
Preparer’s Name:
Preparer’s Signature: Date:
MANDATORY FORM (Page 2 of 3)
STATE OF CALIFORNIA
(08/06)

DWC-AD 10133.53 NOTICE OF OFFER OF MODIFIED OR ALTERNATIVE WORK
For injuries occurring on or after 1/1/04
Proof of Service by Mail
I am a citizen of the United States and a resident of the County of . I am over the age of eighteen
years and not a party to the within matter.
My business address is:
On , I served the Notice of Offer of Modified or Alternative Work on the parties listed below by
placing a true copy thereof enclosed in a sealed envelope with postage fully prepaid, and thereof deposited
in the U. S. Mail at the place so addressed.
I declare under penalty of perjury under the laws of the State of California that the foregoing is true and
correct.
Executed at on .
Signature: -
Copies Served On:
MANDATORY FORM (Page 3 of 3)
STATE OF CALIFORNIA
(08/06)

Supplemental Job Displacement
Nontransferable Trainin2: Voucher Form
(Form DWC-AD 10133.57 - Mandatory Form)
For injuries occuring on or after 1/1/04
You have been determined eligible for this nontransferable. Supplemental Job
Displacement Voucher. This voucher may be used for the payment of tuition. fees.
books. and other expenses required by a state approved or accredited school that you
emoll in for the purose of education related retraining or skil enhancement. or both.
The state approved or accredited school wil be reimbursed upon receipt of a documented
invoice for tuition. fees. books and other required expenses required by the school for
retraining or skil enhancement. If yOU pay for the eligible expenses. yOU may be
reimbursed for these expenses upon submission of documented receipts. No more than 10
vercent of the value of this voucher may be used for vocational or retu to work
counseling. If you decide to voluntarily withdraw from a pro gram. you may not be
entitled to a full refund of the voucher amount utilized.
Please present this original letter to the state approved or accredited school and/or the
Vocational & Retu to Work Counselor of your choice. chosen from the list developed
by the Division of Workers , Compensation's Administrative Director. in order to initiate
your training and retu to work counseling. A list of Vocational & Retu to Work
Counselors is available on the Division of Workers' Compensation's website
ww.dir.ca.gov or upon request. The school and/or counselor should contact me
regarding direct payment from your supplemental job displacement benefit.
Injured Employee. Information: Upon completing the voucher form the injured employee
must retu the form with receipts and documentation to the claims administrator
immediately for reimbursement. (The claims administrator must complete Nos. L - 8 of
this voucher form prior to sending it to the injured employee.)
1. Injured Employee Name
2. Address
City State Zip Code
3. Claim Number Phone Number
Claims Administrator
4. Name
5. Claims Mailing Address
Final Regulations (June 2, 2005) Supplemental Job Displacement Benefit Regulations 16
Title 8, California Code of Regulations, sections 10133.50 - 10133.60

6. City State Zip Code
7. Claims Representative
Phone Number
8. $ is available to the injured employee based on
Partial Disabilitv Award
% of Permanent
The iniured emDloyee must comDlete Nos. 9 -19 and sien and date this voucher
form.
(VRTWC) Vocational Return to Work Counselor (if any)
9. Name Phone Number
10. Address
11. City State Zip Code
12. Funds used for vocational and retu to work counseling $
of voucher value)
(10% maximum
Trainine Provider Details (Attach additional Daees for each Drovider if necessary.)
13. Provider Name
14. Provider Address Phone Number
15. City State Zip Code
16. Provider approval number
17. Expiration Date
18. Provider Contact Name
19. Training Cost
Iniured EmDloyee Sienature Date
Note to Claims Administrator: DDon receiDt of voucher. receiDts and documentation
from the emDloyee. reimbursement Dayments to the emDlovee or direct Davments to
VRTWC and trainine Droviders must be made within 45 calendar days.
Final Regulations (June 2, 2005) Supplemental Job Displacement Benefit Regulations 17
Title 8, California Code of Regulations, sections 10133.50 - 10133.60