Dwc District Office California Form Pack Page 12
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22STATE OF CALIFORNIA
DWC DISTRICT OFFICE
DOCUMENT COVER SHEET
Is this a new case?
Yes
No
Companion Cases Exist
Yes
No
Walkthrough
More than 15 Companion Cases
YOUR SOCIAL
TODAY'S DATE
SECURITY NUMBER
SSN:
Date:(MM/DD/YYYY)
Specific Injury
EAMS CASE NUMBER
DATE OF INJURY
Case Number 1
Cumulative Injury
(Start Date: MM/DD/YYYY)
(End Date: MM/DD/YYYY)
(If Specific Injury, use the start date as the specific date of injury)
IF NEW CASE
LEAVE BLANK
USE CODE FROM
Body Part 1:
Body Part 3:
BODY PART
CODE LIST, SEE
PAGE 8
Body Part 2:
Body Part 4:
WHEN MORE THAN 5 BODY PARTS USE BODY
PART NUMBER 700 IN THIS FIELD
Other Body Parts:
Please check unit to be filed on ( check only one box )
ADJ
DEU
SIF
UEF
INT
RSU
Companion Cases
Specific Injury
Case Number 2
Cumulative Injury
(Start Date: MM/DD/YYYY)
)
(End Date: MM/DD/YYYY
(If Specific Injury, use the start date as the specific date of injury)
Body Part 1:
Body Part 3:
Body Part 2:
Body Part 4:
Other Body Parts:
DWC-CA form 10232.1 Rev. 7/2010 - Page 1 of 8
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