Doctors First Report Of Occupational Injury Or Illness California
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3STATE OF CALIFORNIA
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DOCTOR'S FIRST REPORT OF OCCUPATIONAL INJURY OR ILLNESS
Within 5 days of your initial examination, for every occupational injury or illness, send two 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 Department of Industrial Relations, P.O. Box 420603, San Francisco, CA 94142-0603, and notify your local health
officer by telephone within 24 hours.
1. Insurer Name and Address
2. Employer Name
3. Address
No. and Street
City
Zip Code
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 Birth
8. Address
No. and Street
City
Zip Code
9.Phone Number
10. Occupation (Specific job title)
12. Address No. and Street Where Injury Occurred
11. Social Security Number
City Where Injury Occ.
County
13. Date and hour of injury or onset of illness
16.
Have you or your office previously rendered treatment
14. Date last worked
15.
treatment
Date and hour of 1st exam or
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
19. Objective Findings
A. Physical Examination
B. X-ray and laboratory results (State if none or pending.)
Sheet 1 of 3
Form 5021 (Rev. 5) 10/2015
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