What this form is for
Supplemental job displacement non-transferable voucher * Injuries occurring on or after 1/1/13 - - -
Official file
Published by the Division of Workers' Compensation. This page does not replace the form — it points at the state's PDF and, where the form is what a panel actually ruled on, quotes that ruling.
How to fill a DWC form →Source: dir.ca.gov/dwc/forms.html. Unofficial guide — the PDF on that site is the form.
What the Appeals Board did with this
Decisions of the Workers' Compensation Appeals Board that turned on this kind of filing. Each quotes the passage it turned on and links to the official PDF.
- ADJ10912062 · 2026-10-05 · Long Beach District OfficeSJDB voucherapplicant prevailed
Determinative passage · p.6Here, with respect to the April 13, 2017 injury (ADJ10912062), according to the July 29, 2019 report of Julie Goalwin, Ph.D., applicant was found to be permanent and stationary with a GAF score of 63 and a whole person impairment (WPI) of 11. (Applicant’s Exhibit 2, report of Dr. Goalwin, signed on July 29, 2019 with an examination date of July 17, 2019, p. 22.) An earlier report by Michelle Conover, Ph.D., dated July 1, 2019 found applicant permanent and stationary but without any disability, or a disability that had largely been resolved. (Defendant Exhibit A, report of Dr. Conover dated July 1, 2019, pp. 59, 61.) Dr. Conover’s report would not have entitled applicant to the SJDB voucher as she did not find applicant had suffered any permanent disability. But because the Joint Findings of Fact found applicant to be permanent and stationary on the later date of July 17, 2019 (this is the date of Dr. Goalwin’s examination of application, not the date Dr. Goalwin signed her report), we accept Dr.
Applicant was found permanent and stationary with permanent partial disability for the April 13, 2017 injury and returned to the same job more than 60 days after MMI, so employer is not absolved from SJDB voucher liability for that injury. For the October 26, 2021 injury, applicant returned to work before MMI and satisfied timing requirements, so no voucher is owed.
Official decision · page 6 → - ADJ11126563 · 2026-09-18 · Van Nuys District OfficeSJDB voucherdefendant prevailed
Determinative passage · p.1We previously granted reconsideration 1 to provide an opportunity to further study the legal and factual issues raised by the Petition for Reconsideration filed by applicant. This is our Opinion and Decision After Reconsideration. Applicant seeks reconsideration of the May 9, 2022 Findings of Fact & Order, wherein the workers’ compensation administrative law judge (WCJ) found that applicant is not entitled to reimbursement for education-related training or skill enhancement incurred at the Tree of Life training, which the parties stipulated is not a certified provider per California law. The WCJ also found that there is no evidence to show that the two-year statute of limitations for the Supplemental Job Displacement Benefit (SJDB) voucher was tolled and that the voucher expired by operation of law. Applicant contends that the legislative purpose of the SJDB is to assist injured workers in obtaining gainful employment and that refusal to reimburse applicant for the Tree of Life training defeats the purpose of the SJDB program. Applicant also contends that the statute of limitations tolled during the time period the insurance carrier denied applicant’s claim and pending adjudication of the issue.
The Tree of Life training was not certified or approved under California law, and the voucher expired by operation of law without evidence of tolling. The applicant did not demonstrate entitlement to reimbursement or tolling of the statute of limitations.
Official decision · page 1 → - ADJ9744423 · 2026-03-27 · Sacramento District OfficeSJDB voucherapplicant prevailed
Determinative passage · p.5Here, the WCJ issued a finding that defendant mailed the SJDV to applicant's address on the Official Address Record, which appears correct. However, the unrebutted testimony of applicant is that he was not living at that address at the time of service and that he did not receive the voucher. The WCJ found applicant's testimony credible. (See Garza, supra.) Thus, the evidentiary presumption is rebutted, and we will find that applicant did not receive the SJDV that defendant mailed in 2019.
Applicant's credible testimony that he did not receive the voucher rebutted the presumption of receipt, leading to a finding that applicant did not receive the voucher mailed to the official address record.
Official decision · page 5 → - ADJ13057590 · 2025-08-25 · Van Nuys District OfficeSJDB voucherdefendant prevailed
Determinative passage · p.1Applicant seeks reconsideration of the June 12, 2025 Findings of Fact and Orders (F&O) issued by the workers' compensation administrative law judge (WCJ). By the F&O, as relevant here, the WCJ found defendant produced proof of service for a supplemental job displacement voucher (SJDV), and under Evidence Code section 641, it is presumed that the defendant timely mailed the SJDV and the SJDV was received, and defendant acted reasonably and timely in replacing the voucher upon notice of actual non-receipt. The WCJ also found that though the voucher was not in fact received by applicant, applicant failed in their burden of proof to rebut the presumption and was not entitled to a penalty.
The Appeals Board found that defendant produced proof of service for the voucher, invoking the presumption under Evidence Code section 641 that the voucher was mailed and received. Applicant failed to produce believable contrary evidence to rebut this presumption. The WCJ and Appeals Board found no unreasonable delay warranting penalties or attorney fees.
Official decision · page 1 →