Physician'S Report Of Worker'S Compensation Injury - Delaware Workers' Compensation
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1DELAWARE WORKERS' COMPENSATION
PHYSICIAN'S REPORT OF WORKER'S COMPENSATION INJURY
A COPY OF THIS REPORT MUST BE SENT TO THE INJURED WORKER AND THE INSURER
REPORT TYPE
___ Initial
___Progress
___Closing
WORKER’S NAME_______________________________________________________
SS NO.
_____________________________________
Employer Name
___________________________________
DOB
_____________________________________
Employer Phone/Fax_________________/________________
ACC. DATE
_____________________________________
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
Work Postures: Maximum tolerance in hours for above work day (circle one in each category below):
Sitting:
0
1
2
3
4
5
6
7
8
Standing:
0
1
2
3
4
5
6
7
8
Walking;
0
1
2
3
4
5
6
7
8
Driving:
0
1
2
3
4
5
6
7
8
Comments:___________________________________________________________________________________________
Lift/Carry & Push/Pull:
Lift/Carry
Push/Pull
D.O.T. Classification of Work
check one:
check one:
Sedentary
10 lbs max: occasionally carry small objects
(
)
(
)
Light
up to 20 lbs max: frequently lift/carry up to 10 lbs
(
)
(
)
Medium
up to 50 lbs max. frequently lift/carry up to 25 lbs
(
)
(
)
Heavy
up to 100 lbs max. frequently lift/carry up to 50 lbs
(
)
(
)
Very Heavy
over 100 lbs occasionally; frequently lift/carry over 50 lbs
(
)
(
)
Non-Material Handling:
based on total hrs/day patient can work (circle one in each category below):
Bending:
0%
25%
50%
75%
100%
Turn/Twist:
0%
25%
50%
75%
100%
Kneeling:
0%
25%
50%
75%
100%
Squatting:
0%
25%
50%
75%
100%
Crawling,
0%
25%
50%
75%
100%
Climbing:
0%
25%
50%
75%
100%
Repeated arm motions:
0%
25%
50%
75%
100%
Reaching up above shoulder:
0%
25%
50%
75%
100%
Foot controls:
0%
25%
50%
75%
100%
Comments:____________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Above work restrictions are: temporary _______
permanent _______
anticipated return to work without restrictions ____________
Return to work modified duty start date: __________________________ Next reevaluation date: _______________________________
Physician Signature: _________________________________________________
Date: ________________________________
Physician Name: (Please print ) _________________________________________
Certification No.:________________________
(Rev: 9/11/07)
PROVIDER FORM
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