BETWEEN 1 — Supplemental Job Displacement Nontransferable Training Voucher

PDF · www.dir.ca.gov · 3 pages · 41 fields

FormBETWEEN 1 — Supplemental Job Displacement Nontransferable Training Voucher

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Form: BETWEEN 1 · Issuer: www.dir.ca.gov · Format: pdf · Pages: 3 · Fillable fields: 41 · Languages: en · Version: PDF last modified 2020-11-09

The file · the JSON object · every form at www.dir.ca.gov

Every field

Fields, as the file names and labels them

n	label	data type	pdf kind	pdf name
1	Enter percentage of PD using a decimal and without the percent sign. For example, 25 1/4 % disability should be entered as 25.25.	string	text	PerOfPD[0]
2	Vocational & Return to Work Counselor zip code	string	text	VRCZip[0]
3	Vocational & Return to Work Counselor city	string	text	VocRepCity[0]
4	Vocational & Return to Work Counselor address/PO Box (Please leave blank spaces between numbers, names or words)	string	text	VocRepAddress[0]
5	Vocational & Return to Work Counselor phone.(Numbers only)	string	text	VRPhoneNum[0]
6	Vocational & Return to Work Counselor first name.	string	text	VRRepFirst[0]
7	Vocational & Return to Work Counselor last name.	string	text	VRREpLast[0]
8	Vocational & Return to Work Counselor Middle initial	string	text	VRMI[0]
9	Completion of this field is required. Training provider first name. If the training provider is an institution, put the name of the institution in this box.	string	text	TPFirstName[0]
10	Completion of this field is required. Training provider first name.	string	text	TPLastName[0]
11	Completion of this field is required. Training provider Address/PO Box Please leave blank spaces between numbers, names or words.	string	text	TPaddress[0]
12	Completion of this field is required. Training provider City.	string	text	TPCity[0]
13	Completion of this field is required. Training provider State. Use the Up Arrow and Down Arrow keys to move through the list items. Pressing the Tab key or the Enter or Return key will select the item in the list. Pressing the Tab key or the Enter or Return key will select the item in the list.	enum	combo	TPState[0]
14	Completion of this field is required. Training provider Zip Code.	string	text	TPZip[0]
15	Completion of this field is required. Training provider Phone.(Numbers only)	string	text	PhoneNum[0]
16	Training provider approval number.	string	text	ProviderApprovalNumber[0]
17	Training provider approval expiration date. (MM/DD/YYYY)	string	text	LicExpDate[0]
18	Enter the dollar amount of training costs	string	text	TrainingCost[0]
19	Date of employee signature (MM/DD/YYYY)	string	text	SigningDate[0]
20	Funds used for vocational and return to work counseling $ (10% maximum of voucher value)	string	text	CounselFees[0]
21	Vocational & Return to Work Counselor State. Use the Up Arrow and Down Arrow keys to move through the list items. Pressing the Tab key or the Enter or Return key will select the item in the list.	enum	combo	VRState[0]
22	Training Provider Contact Name.	string	text	ProviderContactName[0]
23	Print Form	string	button	PrintButton1[0]
24	Completion of this field is required. Employee Zip Code.	string	text	EmployeeZipCode[0]
25	Employee middle initial	string	text	EmployeeInitial[0]
26	Completion of this field is required. Employee first name.	string	text	EmployeeFirstName[0]
27	Completion of this field is required. Employee last name.	string	text	EmployeeLastName[0]
28	Completion of this field is required. Employee Address/PO Box Please leave blank spaces between numbers, names or words.	string	text	EmployeeAddress[0]
29	Completion of this field is required. Employee City.	string	text	EmployeeCity[0]
30	Completion of this field is required. Claim number.	string	text	Claim_No[0]
31	Employee phone number.(Numbers only)	string	text	PhoneNum[0]
32	Completion of this field is required. Date of Birth.(MM/DD/YYYY)	string	text	DateOFBirthField[0]
33	Claims administrator zip code.	string	text	ClaimsAdministratorZip[0]
34	Claims administrator state. Use the Up Arrow and Down Arrow keys to move through the list items. Pressing the Tab key or the Enter or Return key will select the item in the list.	enum	combo	ClaimsAdministratorState[0]
35	Claims administrator city.	string	text	ClaimsAdministratorCity[0]
36	Claims Administrator Mailing Address (Please leave blank spaces between numbers, names or words)	string	text	ClaimsAdministratorAddress[0]
37	Claims administrator name(Please leave blank spaces between numbers, names or words.)	string	text	ClaimaAdministratorName[0]
38	Completion of this field is required. Employee State. Use the Up Arrow and Down Arrow keys to move through the list items. Pressing the Tab key or the Enter or Return key will select the item in the list.	enum	combo	EmployeeState[0]
39	Insert the dollar amount of the voucher.	string	text	Money[0]
40	Claims representative phone number.	string	text	ClaimsAdminPhoneNum[0]
41	Reset Form	string	button	ResetButton1[0]
42	Claims Representative	string	text	ClaimsRep[0]
43	Injured Employee Signature	signature	signature	Signature1

Where it was found

page	source
https://www.dir.ca.gov/dwc/forms.html	src_48d0bc8290
https://www.dir.ca.gov/dwc/forms.html	src_2d2568d2e9
https://www.dir.ca.gov/dwc/forms.html	src_5de2f5c0d1
https://www.dir.ca.gov/dwc/forms.html	src_1ea79457e3
https://www.dir.ca.gov/dwc/forms.html	src_3c4f9ab07e
https://www.dir.ca.gov/dwc/forms.html	src_9d0104a86b
https://www.dir.ca.gov/dwc/forms.html	src_e8d0cea5d1
https://www.dir.ca.gov/dwc/forms.html	src_a098a010e3

The object

What the file says about itself

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References (1)

Supplemental Job Displacement Nontransferable Training Voucher — www.dir.ca.gov

Page data

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        "field_id": "f:perofpd_0",
        "label": "Enter percentage of PD using a decimal and without the percent sign. For example, 25 1/4 % disability should be entered as 25.25.",
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        "field_id": "f:vrreplast_0",
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      {
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        "label": "Completion of this field is required. Training provider Address/PO Box Please leave blank spaces between numbers, names or words.",
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        "field_id": "f:tpcity_0",
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        "pdf_kind": "text",
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      {
        "field_id": "f:tpstate_0",
        "label": "Completion of this field is required. Training provider State. Use the Up Arrow and Down Arrow keys to move through the list items. Pressing the Tab key or the Enter or Return key will select the item in the list. Pressing the Tab key or the Enter or Return key will select the item in the list.",
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        "label": "Completion of this field is required. Training provider Zip Code.",
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        "field_id": "f:phonenum_0",
        "label": "Completion of this field is required. Training provider Phone.(Numbers only)",
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        "pdf_kind": "text",
        "max_length": 10
      },
      {
        "field_id": "f:providerapprovalnumber_0",
        "label": "Training provider approval number.",
        "data_type": "string",
        "pdf_name": "ProviderApprovalNumber[0]",
        "pdf_kind": "text",
        "max_length": 20
      },
      {
        "field_id": "f:licexpdate_0",
        "label": "Training provider approval expiration date. (MM/DD/YYYY)",
        "data_type": "string",
        "pdf_name": "LicExpDate[0]",
        "pdf_kind": "text"
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      {
        "field_id": "f:trainingcost_0",
        "label": "Enter the dollar amount of training costs",
        "data_type": "string",
        "pdf_name": "TrainingCost[0]",
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        "label": "Date of employee signature (MM/DD/YYYY)",
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      {
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        "label": "Funds used for vocational and return to work counseling $ (10% maximum of voucher value)",
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      {
        "field_id": "f:employeeinitial_0",
        "label": "Employee middle initial",
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        "field_id": "f:employeelastname_0",
        "label": "Completion of this field is required. Employee last name.",
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        "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.",
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        "field_id": "f:employeecity_0",
        "label": "Completion of this field is required. Employee City.",
        "data_type": "string",
        "pdf_name": "EmployeeCity[0]",
        "pdf_kind": "text",
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      {
        "field_id": "f:claim_no_0",
        "label": "Completion of this field is required. Claim number.",
        "data_type": "string",
        "pdf_name": "Claim_No[0]",
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        "field_id": "f:dateofbirthfield_0",
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        "pdf_name": "DateOFBirthField[0]",
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        "field_id": "f:claimsadministratorzip_0",
        "label": "Claims administrator  zip code.",
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      {
        "field_id": "f:claimsadministratorstate_0",
        "label": "Claims administrator  state. Use the Up Arrow and Down Arrow keys to move through the list items. Pressing the Tab key or the Enter or Return key will select the item in the list.",
        "data_type": "enum",
        "pdf_name": "ClaimsAdministratorState[0]",
        "pdf_kind": "combo"
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      {
        "field_id": "f:claimsadministratorcity_0",
        "label": "Claims administrator city.",
        "data_type": "string",
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        "pdf_kind": "text",
        "max_length": 25
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      {
        "field_id": "f:claimsadministratoraddress_0",
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        "data_type": "string",
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        "pdf_kind": "text",
        "max_length": 40
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        "field_id": "f:claimaadministratorname_0",
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        "pdf_kind": "text",
        "max_length": 56
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        "field_id": "f:employeestate_0",
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        "data_type": "enum",
        "pdf_name": "EmployeeState[0]",
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        "field_id": "f:signature1",
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      "url": "https://www.dir.ca.gov/dwc/forms/SJDB/10133.57.pdf",
      "date": "2026-10-09T17:14:40.099Z"
    }
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    "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",
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    "bytes": 808023,
    "authority_id": "www.dir.ca.gov",
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    "jurisdiction": null,
    "source_url": "https://www.dir.ca.gov/dwc/forms/SJDB/10133.57.pdf",
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    "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. For example, 25 1/4 % disability should be entered as 25.25.",
        "data_type": "string",
        "pdf_name": "PerOfPD[0]",
        "pdf_kind": "text"
      },
      {
        "field_id": "f:vrczip_0",
        "label": "Vocational & Return to Work Counselor zip code",
        "data_type": "string",
        "pdf_name": "VRCZip[0]",
        "pdf_kind": "text",
        "max_length": 5
      },
      {
        "field_id": "f:vocrepcity_0",
        "label": "Vocational & Return to Work Counselor city",
        "data_type": "string",
        "pdf_name": "VocRepCity[0]",
        "pdf_kind": "text",
        "max_length": 25
      },
      {
        "field_id": "f:vocrepaddress_0",
        "label": "Vocational & Return to Work Counselor address/PO Box (Please leave blank spaces between numbers, names or words)",
        "data_type": "string",
        "pdf_name": "VocRepAddress[0]",
        "pdf_kind": "text",
        "max_length": 40
      },
      {
        "field_id": "f:vrphonenum_0",
        "label": "Vocational & Return to Work Counselor phone.(Numbers only)",
        "data_type": "string",
        "pdf_name": "VRPhoneNum[0]",
        "pdf_kind": "text",
        "max_length": 10
      },
      {
        "field_id": "f:vrrepfirst_0",
        "label": "Vocational & Return to Work Counselor first name.",
        "data_type": "string",
        "pdf_name": "VRRepFirst[0]",
        "pdf_kind": "text",
        "max_length": 25
      },
      {
        "field_id": "f:vrreplast_0",
        "label": "Vocational & Return to Work Counselor last name.",
        "data_type": "string",
        "pdf_name": "VRREpLast[0]",
        "pdf_kind": "text",
        "max_length": 25
      },
      {
        "field_id": "f:vrmi_0",
        "label": "Vocational & Return to Work Counselor Middle initial",
        "data_type": "string",
        "pdf_name": "VRMI[0]",
        "pdf_kind": "text",
        "max_length": 1
      },
      {
        "field_id": "f:tpfirstname_0",
        "label": "Completion of this field is required. Training provider first name. If the training provider is an institution, put the name of the institution in this box.",
        "data_type": "string",
        "pdf_name": "TPFirstName[0]",
        "pdf_kind": "text",
        "max_length": 25
      },
      {
        "field_id": "f:tplastname_0",
        "label": "Completion of this field is required. Training provider first name.",
        "data_type": "string",
        "pdf_name": "TPLastName[0]",
        "pdf_kind": "text",
        "max_length": 25
      },
      {
        "field_id": "f:tpaddress_0",
        "label": "Completion of this field is required. Training provider Address/PO Box Please leave blank spaces between numbers, names or words.",
        "data_type": "string",
        "pdf_name": "TPaddress[0]",
        "pdf_kind": "text",
        "max_length": 40
      },
      {
        "field_id": "f:tpcity_0",
        "label": "Completion of this field is required. Training provider City.",
        "data_type": "string",
        "pdf_name": "TPCity[0]",
        "pdf_kind": "text",
        "max_length": 25
      },
      {
        "field_id": "f:tpstate_0",
        "label": "Completion of this field is required. Training provider State. Use the Up Arrow and Down Arrow keys to move through the list items. Pressing the Tab key or the Enter or Return key will select the item in the list. Pressing the Tab key or the Enter or Return key will select the item in the list.",
        "data_type": "enum",
        "pdf_name": "TPState[0]",
        "pdf_kind": "combo"
      },
      {
        "field_id": "f:tpzip_0",
        "label": "Completion of this field is required. Training provider Zip Code.",
        "data_type": "string",
        "pdf_name": "TPZip[0]",
        "pdf_kind": "text",
        "max_length": 5
      },
      {
        "field_id": "f:phonenum_0",
        "label": "Completion of this field is required. Training provider Phone.(Numbers only)",
        "data_type": "string",
        "pdf_name": "PhoneNum[0]",
        "pdf_kind": "text",
        "max_length": 10
      },
      {
        "field_id": "f:providerapprovalnumber_0",
        "label": "Training provider approval number.",
        "data_type": "string",
        "pdf_name": "ProviderApprovalNumber[0]",
        "pdf_kind": "text",
        "max_length": 20
      },
      {
        "field_id": "f:licexpdate_0",
        "label": "Training provider approval expiration date. (MM/DD/YYYY)",
        "data_type": "string",
        "pdf_name": "LicExpDate[0]",
        "pdf_kind": "text"
      },
      {
        "field_id": "f:trainingcost_0",
        "label": "Enter the dollar amount of training costs",
        "data_type": "string",
        "pdf_name": "TrainingCost[0]",
        "pdf_kind": "text"
      },
      {
        "field_id": "f:signingdate_0",
        "label": "Date of employee signature (MM/DD/YYYY)",
        "data_type": "string",
        "pdf_name": "SigningDate[0]",
        "pdf_kind": "text"
      },
      {
        "field_id": "f:counselfees_0",
        "label": "Funds used for vocational and return to work counseling $ (10% maximum of voucher value)",
        "data_type": "string",
        "pdf_name": "CounselFees[0]",
        "pdf_kind": "text"
      },
      {
        "field_id": "f:vrstate_0",
        "label": "Vocational & Return to Work Counselor State. Use the Up Arrow and Down Arrow keys to move through the list items. Pressing the Tab key or the Enter or Return key will select the item in the list.",
        "data_type": "enum",
        "pdf_name": "VRState[0]",
        "pdf_kind": "combo"
      },
      {
        "field_id": "f:providercontactname_0",
        "label": "Training Provider Contact Name.",
        "data_type": "string",
        "pdf_name": "ProviderContactName[0]",
        "pdf_kind": "text",
        "max_length": 40
      },
      {
        "field_id": "f:printbutton1_0",
        "label": "Print Form",
        "data_type": "string",
        "pdf_name": "PrintButton1[0]",
        "pdf_kind": "button"
      },
      {
        "field_id": "f:employeezipcode_0",
        "label": "Completion of this field is required. Employee Zip Code.",
        "data_type": "string",
        "pdf_name": "EmployeeZipCode[0]",
        "pdf_kind": "text",
        "max_length": 5
      },
      {
        "field_id": "f:employeeinitial_0",
        "label": "Employee middle initial",
        "data_type": "string",
        "pdf_name": "EmployeeInitial[0]",
        "pdf_kind": "text",
        "max_length": 1
      },
      {
        "field_id": "f:employeefirstname_0",
        "label": "Completion of this field is required. 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. Claim number.",
        "data_type": "string",
        "pdf_name": "Claim_No[0]",
        "pdf_kind": "text",
        "max_length": 20
      },
      {
        "field_id": "f:phonenum_0",
        "label": "Employee phone number.(Numbers only)",
        "data_type": "string",
        "pdf_name": "PhoneNum[0]",
        "pdf_kind": "text",
        "max_length": 10
      },
      {
        "field_id": "f:dateofbirthfield_0",
        "label": "Completion of this field is required. Date of Birth.(MM/DD/YYYY)",
        "data_type": "string",
        "pdf_name": "DateOFBirthField[0]",
        "pdf_kind": "text"
      },
      {
        "field_id": "f:claimsadministratorzip_0",
        "label": "Claims administrator  zip code.",
        "data_type": "string",
        "pdf_name": "ClaimsAdministratorZip[0]",
        "pdf_kind": "text",
        "max_length": 5
      },
      {
        "field_id": "f:claimsadministratorstate_0",
        "label": "Claims administrator  state. Use the Up Arrow and Down Arrow keys to move through the list items. Pressing the Tab key or the Enter or Return key will select the item in the list.",
        "data_type": "enum",
        "pdf_name": "ClaimsAdministratorState[0]",
        "pdf_kind": "combo"
      },
      {
        "field_id": "f:claimsadministratorcity_0",
        "label": "Claims administrator city.",
        "data_type": "string",
        "pdf_name": "ClaimsAdministratorCity[0]",
        "pdf_kind": "text",
        "max_length": 25
      },
      {
        "field_id": "f:claimsadministratoraddress_0",
        "label": "Claims Administrator Mailing Address (Please leave blank spaces between numbers, names or words)",
        "data_type": "string",
        "pdf_name": "ClaimsAdministratorAddress[0]",
        "pdf_kind": "text",
        "max_length": 40
      },
      {
        "field_id": "f:claimaadministratorname_0",
        "label": "Claims administrator name(Please leave blank spaces between numbers, names or words.)",
        "data_type": "string",
        "pdf_name": "ClaimaAdministratorName[0]",
        "pdf_kind": "text",
        "max_length": 56
      },
      {
        "field_id": "f:employeestate_0",
        "label": "Completion of this field is required. Employee State. Use the Up Arrow and Down Arrow keys to move through the list items. Pressing the Tab key or the Enter or Return key will select the item in the list.",
        "data_type": "enum",
        "pdf_name": "EmployeeState[0]",
        "pdf_kind": "combo"
      },
      {
        "field_id": "f:money_0",
        "label": "Insert the dollar amount of the voucher.",
        "data_type": "string",
        "pdf_name": "Money[0]",
        "pdf_kind": "text"
      },
      {
        "field_id": "f:claimsadminphonenum_0",
        "label": "Claims representative phone number.",
        "data_type": "string",
        "pdf_name": "ClaimsAdminPhoneNum[0]",
        "pdf_kind": "text",
        "max_length": 10
      },
      {
        "field_id": "f:resetbutton1_0",
        "label": "Reset Form",
        "data_type": "string",
        "pdf_name": "ResetButton1[0]",
        "pdf_kind": "button"
      },
      {
        "field_id": "f:claimsrep_0",
        "label": "Claims Representative",
        "data_type": "string",
        "pdf_name": "ClaimsRep[0]",
        "pdf_kind": "text",
        "max_length": 56
      },
      {
        "field_id": "f:signature1",
        "label": "Injured Employee Signature",
        "data_type": "signature",
        "pdf_name": "Signature1",
        "pdf_kind": "signature"
      }
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