Doctor'S First Report Of Occupational Injury Or Illness Template
ADVERTISEMENT
1STATE OF CALIFORNIA
DOCTOR'S FIRST REPORT OF OCCUPATIONAL INJURY OR ILLNESS
Within 5 days of your initial examination, for every occupational injury or illness, send tow copies of this report to the employer's workers' compensation
insurance carrier or the insured employer. Failure to file a timely doctor's report may result in assessment of a civil penalty. In the case of diagnosed or
suspected pesticide poisoning, send a copy of the report to Division of Labor Statistics and Research, P.O. Box 420603, San Francisco, CA 94142-0603, and
notify your local health officer by telephone within 24 hours.
PLEASE DO NOT
1. INSURER NAME AND ADDRESS
USE THIS
COLUMN
2. EMPLOYER NAME
Case No.
3. Address
No. and Street
City
Zip
Industry
County
4. Nature of business (e.g., food manufacturing, building construction, retailer of women's clothes.)
5. PATIENT NAME (first name, middle initial, last name)
6. Sex
7. Date of
Mo.
Day
Yr.
Age
• Male
• Female
Birth
Hazard
8. Address:
No. and Street
City
Zip
9. Telephone number
(
)
10. Occupation (Specific job title)
11. Social Security Number
Disease
-
-
12. Injured at:
No. and Street
City
County
Hospitalization
Occupation
13. Date and hour of injury
Mo. Day
Yr.
Hour
14. Date last worked
Mo. Day Yr.
or onset of illness
a.m.
p.m.
15. Date and hour of first
Mo.
Day
Yr.
Hour
16. Have you (or your office) previously
Return Date/Code
• Yes • No
examination or treatment
a.m.
p.m.
treated patient?
Patient please complete this portion, if able to do so. Otherwise, doctor please complete immediately, inability or failure of a patient to complete this portion shall
not affect his/her rights to workers' compensation under the California Labor Code.
17. DESCRIBE HOW THE ACCIDENT OR EXPOSURE HAPPENED. (Give specific object, machinery or chemical. Use reverse side if more space is
required.)
18. SUBJECTIVE COMPLAINTS (Describe fully. Use reverse side if more space is required.)
19. OBJECTIVE FINDINGS (Use reverse side if more space is required.)
A. Physical examination
B. X-ray and laboratory results (State if non or pending.)
• Yes • No
20. DIAGNOSIS (if occupational illness specify etiologic agent and duration of exposure.) Chemical or toxic compounds involved?
ICD-9 Code ___ ___ ___ - ___ ___
21. Are your findings and diagnosis consistent with patient's account of injury or onset of illness? • Yes • No If "no", please explain.
22. Is there any other current condition that will impede or delay patient's recovery? • Yes
• No
If "yes", please explain.
23. TREATMENT RENDERED (Use reverse side if more space is required.)
24. If further treatment required, specify treatment plan/estimated duration.
25. If hospitalized as inpatient, give hospital name and location
Date
Mo. Day Yr.
Estimated stay
admitted
• Yes
• No
26. WORK STATUS -- Is patient able to perform usual work?
If "no", date when patient can return to:
Regular work
____/____/____
Modified work ____/____/____
Specify restrictions ______________________________________________
Doctor's Signature ______________________________________________________
CA License Number ________________________________
Doctor Name and Degree (please type) ______________________________________
IRS Number ________________________________
2315 Stockton Blvd., Sacramento, CA 95817
Address _______________________________________________________________
Telephone Number (_____)__________________________
FORM 5021 (Rev. 4)
1992
Any person who makes or causes to be made any knowingly false or fraudulent material statement or material representation
for the purpose of obtaining or denying workers' compensation benefits or payments is guilty of a felony.
A 1578 (4/93)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Tennessee Department Of Labor And Workforce Development Employer's First Report Of Work Injury Or Illness
Legal
Form 8wc - Employer's First Report Of Occupational Injury Or Disease - The State Of New Hampshire, Department Of Labor
Legal
Related Categories
Parent category: Business