For California injuries on or after January 1, 2013, the first physician who finds every claimed condition permanent and stationary with permanent partial disability completes this report. It tells the employer the employee's work capacities and activity restrictions so it can offer regular, modified or alternative work, or issue the Supplemental Job Displacement Benefit voucher.
The first primary treating physician, QME or AME to make that finding completes the form. The job description section is completed only if the employer or claims administrator provided a job description.
Download the current version from the source each time; forms change without notice.
Physician's Return-to-Work & Voucher Report
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
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The first physician, whether the primary treating physician, a QME or an AME, who finds that disability from all claimed conditions has become permanent and stationary, or reached maximum medical improvement, and that the injury caused permanent partial disability. It does not need completing until every claimed condition is permanent and stationary.
Yes. DWC calls it a mandatory attachment to the first medical report finding all conditions permanent and stationary with permanent partial disability. It is attached to, and does not replace, a comprehensive medical-legal evaluation when a QME or AME makes that finding.
No. The instructions state that the work capacities and restrictions on the form are for voucher purposes and are not considered in any permanent impairment rating or permanent disability indemnity. The rating comes from the medical report the form is attached to.