Physician'S Form Instructions/definitions Page 2
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2DELAWARE WORKERS' COMPENSATION
PHYSICIAN'S REPORT OF WORKER'S COMPENSATION INJURY
A COPY OF THIS REPORT MUST BE SENT TO THE INJURED WORKER, EMPLOYER AND THE INSURER
REPORT TYPE
___ Initial
___Progress
___Closing
WORKER’S NAME_____________________________________________________
Employer Name
_________________________________
DOB
_______________________
Employer Phone/Fax
_________________________________
Date of Injury
_______________________
Insurer Name
_________________________________
EXAM DATE
_______________________
Insurer Claim No.
_________________________________
Physician’s Phone/Fax_____________________
Insurer Phone/Fax
_________________________________
INITIAL VISIT ONLY
Injured worker’s description of accident/injury____________________________________________________________________
_________________________________________________________________________________________________________
WORK RELATED MEDICAL DIAGNOSIS (ES) ________________________________________________________________
_________________________________________________________________________________________________________
TREATMENT PLAN:
Diagnostic Tests____________________________________________________________________________________________
Procedures________________________________________________________________________________________________
Therapy__________________________________________________________________________________________________
Medications_______________________________________________________________________________________________
Hrs. per day patient can work: (circle one)
8
6
4
2
0
D.O.T. Classification of Work (Circle one)
Sedentary
Exerting up to 10 lbs. of force occasionally and/or a negligible amount of force frequently to lift, carry, push, pull or otherwise move objects,
including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time.
Light
Exerting up to 20 lbs. of force occasionally and/or up to 10 lbs. of force frequently and/or negligible amount of force constantly to move objects.
Physical demand requirements are in excess of those for Sedentary Work.
Medium
Exerting 20 to 50 lbs. of force occasionally and/or 10 to 25 lbs. of force frequently and or greater than negligible up to 10 lbs. of force constantly
to move objects. Physical Demand requirements are in excess of those for Light Work.
Heavy
Exerting 50 to 100 lbs. of force occasionally and/or 25 to 50 lbs. of force frequently and/or 10 to 20 lbs. of force constantly to move objects.
Physical Demand requirements are in excess of those for Medium Work.
Very Heavy Exerting in excess of 100 lbs. of force occasionally and/or in excess of 50 lbs. of force frequently and/or in excess of 20
lbs. of force constantly to move objects. Physical Demand requirements are in excess of those for Heavy Work.
Definitions:
Occasionally: activity or condition exists up to 1/3 of the time
Frequently: activity or condition exists from 1/3 to 2/3 of the time
Constantly: activity or condition exists 2/3 or more of the time
Work Postures/Positional tolerances: Comment as appropriate in the space provided regarding the patient’s abilities/limitations for the following
Postures/Positions. (e.g. Sitting: No more than 30 minutes continuously)
Sitting:
____________________________________
Squatting:
_________________________________________
Standing: ____________________________________
Crawling:
_________________________________________
Walking: ____________________________________
Climbing:
_________________________________________
Driving: ____________________________________
Repeated arm motions: ________________________________
Bending: ____________________________________
Repetitive use of wrist/hands: ____________________________
Turn/Twist: _________________________________
Reaching up above shoulder: _____________________________
Kneeling:
__________________________________
Foot controls: ________________________________________
Comments:_______________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
Above safe work capacities are:
temporary _______
permanent _______
anticipate full duty release ____________
Return to work modified duty start date: ____________________________________________________________
RELEASE TO FULL DUTY WITH NO RESTRICTIONS (Please Circle) YES (Start date_______________)
NO
Physician Signature: ___________________________________________ Date: ___________________________
Physician Name: (Please print ) ____________________________________ Certified Provider:: YES
NO
PROVIDER FORM
Revised 03/2011
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