{"schema":"page/1","id":"form:frm_00234b94cf51","kind":"FormDocument","layout":"item","status":"published","title":"BETWEEN 1 — Supplemental Job Displacement Nontransferable Training Voucher","summary":"PDF · www.dir.ca.gov · 3 pages · 41 fields","hero":"","body":"","sources":[{"title":"Original form","url":"https://www.dir.ca.gov/dwc/forms/SJDB/10133.57.pdf","date":"2026-10-09T17:14:40.099Z"}],"widgets":[],"tags":[],"members":[],"relations":[],"query":{},"media":[],"created":"2026-10-09T17:14:40.099Z","updated":"2026-10-09T17:14:40.099Z","facts":{"schema":"form-object/1","id":"frm_00234b94cf51","form_id":"frm_00234b94cf51","form_name":"Supplemental Job Displacement Nontransferable Training Voucher","form_number":"BETWEEN 1","form_number_read_from":"SUPPLEMENTAL JOB DISPLACEMENT NONTRANSFERABLE TRAINING VOUCHER FORM FOR INJURIES OCCURRING BETWEEN 1/1/04-12/31/12, INCLUSIVE DWC - AD 10133.57","version":"PDF last modified 2020-11-09","format":"pdf","content_type":"application/pdf","bytes":808023,"authority_id":"www.dir.ca.gov","authority":null,"jurisdiction":null,"source_url":"https://www.dir.ca.gov/dwc/forms/SJDB/10133.57.pdf","final_url":null,"artifact_hash":"sha256:881e557b2fcb723e029b4ef09a446f1c904a9396e45221f2d3ab319e9dcb7e5e","stored_artifact":null,"page_count":3,"fillable":true,"field_count":41,"field_kinds":{"text":36,"combo":4,"button":2,"signature":1},"fields":[{"field_id":"f:perofpd_0","label":"Enter percentage of PD using a decimal and without the percent sign. 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Employee first name.","data_type":"string","pdf_name":"EmployeeFirstName[0]","pdf_kind":"text","max_length":25},{"field_id":"f:employeelastname_0","label":"Completion of this field is required. Employee last name.","data_type":"string","pdf_name":"EmployeeLastName[0]","pdf_kind":"text","max_length":25},{"field_id":"f:employeeaddress_0","label":"Completion of this field is required. Employee Address/PO Box Please leave blank spaces between numbers, names or words.","data_type":"string","pdf_name":"EmployeeAddress[0]","pdf_kind":"text","max_length":40},{"field_id":"f:employeecity_0","label":"Completion of this field is required. Employee City.","data_type":"string","pdf_name":"EmployeeCity[0]","pdf_kind":"text","max_length":25},{"field_id":"f:claim_no_0","label":"Completion of this field is required. 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