Return-to-Work Supplement Program (RTWSP)

Privacy Notice on Collection of Personal Information

WARNING: Any person who knowingly makes, or uses a false record or statement that is material to a claim is liable for triple damages plus a civil penalty of not less than $5,500 and not more than $11,000, plus the cost of the action pursuant to the False Claims Act. (Government Code sections 12650-12656). 8 C.C.R. § 17310

Privacy Notice on Collection of Personal Information:  The Department of Industrial Relations will use the personal information collected below to determine your eligibility for, and pay the benefit authorized by Labor Code § 139.48. Your injury history will be used to confirm your identity, and to determine your eligibility. You must provide your Social Security number (SSN) (or federal tax identification number/ITIN) to receive this benefit (8 C.C.R. § 17306).   Your SSN (or ITIN) will be used to match your application to the correct return to work documents, which must be reviewed in the eligibility determination process, and will be provided to the State Controller’s Office for payment processing and accounting.  Failure to provide your name, address, or SSN (or ITIN) will result in a denial of benefits. The department may share this information for general law enforcement or research purposes. California’s Information Practices Act (Civil Code Section 1798 et seq.) governs the department’s collection and use of individuals’ personal information. The department’s privacy policy, including privacy officer contact information, is available at http://www.dir.ca.gov/od_pub/privacy.html.

Caution: Is your computer secure?

April 2017