Dwc Form-73 - Texas Workers' Compensation Work Status Report
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1
2Employee - You are required to report your injury to your employer within 30 days if
Empleado - Es necesario que reporte su lesión a su empleador dentro de 30 días a partir de la
your employer has workers’ compensation insurance. You have the right to free
fecha en que se lesionó si es que su empleador cuenta con un seguro de compensación para
assistance from the Texas Department of Insurance, Division of Workers’
trabajadores. Usted tiene derecho a recibir asistencia gratuita por parte de la División de
Compensation and may be entitled to certain medical and income benefits. For
Compensación para Trabajadores, y también puede tener derecho a ciertos beneficios médicos y
further information call your local Division field office or 1(800)-252-7031.
monetarios. Para mayor información comuníquese con la oficina local de la División al teléfono
1-800-252-7031.
TEXAS WORKERS’ COMPENSATION WORK STATUS REPORT
5. Doctor's Name and Degree
(for transmission purposes only)
Date Being Sent
PART I: GENERAL INFORMATION
1. Injured Employee's Name
6. Clinic/Facility Name
9.
Employer's Name
2. Date of Injury
3. Social Security Number
7. Clinic/Facility/Doctor Phone & Fax
10. Employer’s Fax # or Email Address (if known)
4. Employee’s Description of Injury/Accident
8. Clinic/Facility/Doctor Address (street address)
11. Insurance Carrier
City
State
Zip
12. Carrier’s Fax # or Email Address (if known)
PART II: WORK STATUS INFORMATION
(FULLY COMPLETE ONE INCLUDING ESTIMATED DATES AND DESCRIPTION IN 13(c) AS APPLICABLE)
13. The injured employee’s medical condition resulting from the workers’ compensation injury:
(a)
will allow the employee to return to work as of __________ (date) without restrictions.
(b)
will allow the employee to return to work as of __________ (date) with the restrictions identified in PART III, which are expected to last
through __________ (date).
(c)
has prevented and still prevents the employee from returning to work as of __________ (date) and is expected to continue through
__________ (date). The following describes how this injury prevents the employee from returning to work:
PART III: ACTIVITY RESTRICTIONS*
(ONLY COMPLETE IF BOX 13(b) IS CHECKED)
14. POSTURE RESTRICTIONS (if any):
17. MOTION RESTRICTIONS (if any):
(if any):
19. MISC. RESTRICTIONS
Max Hours per day: 0 2 4 6 8
Other
Max Hours per day:
0
2 4 6 8 Other
Max hours per day of work: _______
Sit/Stretch breaks of ______ per ______
Standing
Walking
Must wear splint/cast at work
Sitting
Climbing
stairs/ladders
Kneeling/Squatting
Must use crutches at all times
Grasping/Squeezing
No driving/operating heavy equipment
Bending/Stooping
Wrist
flexion/extension
Can only drive automatic transmission
Pushing/Pulling
Reaching
No work /
hours/day work:
Twisting
Overhead Reaching
in extreme hot/cold environments
Other: __________
Keyboarding
15. RESTRICTIONS SPECIFIC TO (if applicable):
at heights or on scaffolding
Other: ____________
L Hand/Wrist
R Hand/Wrist
18. LIFT/CARRY RESTRICTIONS (if any):
Must keep _______________________:
L Arm
R Arm
Neck
May not lift/carry objects more than ____lbs.
Elevated
Clean & Dry
L Leg
R Leg
Back
No skin contact with: ________________
for more than ____ hours per day
May not perform any lifting/carrying
Dressing changes necessary at work
L Foot/Ankle
R Foot/Ankle
Other:______________________________
Other: _______________________________
No Running
16. OTHER RESTRICTIONS (if any):
20. MEDICATION RESTRICTIONS (if any):
Must take prescription medication(s)
Advised to take over-the-counter meds
* These restrictions are based on the doctor’s best understanding of the employee’s essential job functions. If a
Medication may make drowsy (possible
particular restriction does not apply, it should be disregarded. If modified duty that meets these restrictions is not
Safety/driving issues)
available, the patient should be considered to be off work. Note - these restrictions should be followed outside of work
as well as at work.
PART IV: TREATMENT/FOLLOW-UP APPOINTMENT INFORMATION
21. Work Injury Diagnosis Information:
22. Expected Follow-up Services Include:
Evaluation by the treating doctor on ____________________________ (date) at ____ : ____ am/pm
__________________________________
Referral to/Consult with_______________________ on ____________ (date) at ____ : ____ am/pm
Physical medicine __ X per week for __ weeks starting on __________ (date) at ____ : ____ am/pm
__________________________________
Special studies (list): __________________________ on __________ (date) at ____ : ____ am/pm
None. This is the last scheduled visit for this problem. At this time, no further medical care is anticipated.
Date / Time of Visit
EMPLOYEE’S SIGNATURE
DOCTOR’S SIGNATURE
Visit Type:
Role of Doctor:
Treating doctor
Initial
Designated doctor
Referral doctor
___________________
Carrier-selected RME
Consulting doctor
Follow-up
Discharge Time
DWC-selected RME
Other doctor
DWC FORM-73 (Rev. 10/05) Page 1
DIVISION OF WORKERS’ COMPENSATION
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