Every physician who treats a California worker for an occupational injury or illness files this three-sheet report after the first examination. It records the employer and insurer, how the injury happened, subjective complaints, exam and test findings, up to 12 ICD-10 diagnoses, treatment, the plan and work status. Copies go to the claims administrator, which currently mails a copy to the Department of Industrial Relations.
The treating physician completes the report and signs the declaration; under 8 CCR 9785 that includes the primary treating physician, emergency and urgent care physicians, and each new primary treating physician. Item 17, how the injury happened, is for the patient to complete if able, otherwise the doctor completes it.
The header restates the rule: within 5 days of your initial examination, for every occupational injury or illness, send two copies to the employer's workers' compensation insurance carrier or the insured employer. Failure to file a timely report may result in a civil penalty. For diagnosed or suspected pesticide poisoning, also send a copy to the Department of Industrial Relations and notify the local health officer by telephone within 24 hours.
Enter the insurer, the employer's name and address, and the nature of the employer's business, described specifically. Then the patient's name, sex, date of birth, address, phone number, specific job title and Social Security number; the address, city and county where the injury occurred; the date and hour of injury or onset of illness; the date last worked; the date and hour of the first exam or treatment; and whether your office treated the patient before.
This portion is for the patient, if able, and asks for the specific object, machinery or chemical involved, using the reverse side if more space is needed. If the patient cannot complete it, the doctor completes it immediately; the form states that a patient's inability or failure to do so does not affect workers' compensation rights. Physicians using computerized systems keep the employee's statement with the medical record.
Item 18 records the patient's subjective complaints. Item 19 has two parts: A, the physical examination findings, and B, X-ray and laboratory results. For part B the form asks you to state if results are none or pending, so do not leave that space empty even when no imaging or laboratory tests were ordered.
List up to 12 diagnoses with ICD-10 codes. For an occupational illness, specify the etiologic agent and duration of exposure, and answer whether chemical or toxic compounds were involved. Item 21 asks whether your findings and diagnosis are consistent with the patient's account of the injury or onset of illness, with an explanation if not. Item 22 asks about any other current condition that will impede or delay recovery.
Item 23 describes the treatment rendered, using the reverse side if more space is required. Item 24 gives the treatment plan and estimated duration if further treatment is required. Item 25 applies only when the patient is hospitalized as an inpatient and asks for the hospital name and location, the date admitted and the estimated length of stay.
State whether the patient is able to perform his or her usual work by checking Yes or No. If No, enter the date the patient can return and mark whether that return is to regular work or to modified work, then specify the restrictions in the space provided at the bottom of Sheet 2.
Sign with an original signature, not a stamp. The declaration states under penalty of perjury that the report is true and correct to the best of your knowledge and that you have not violated Labor Code section 139.3. Add your California license number, where the report was executed, the date (mm/dd/yyyy), your name, specialty, address and phone number. A fraud warning and DWC's privacy notice follow.
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Doctor's First Report of Occupational Injury or Illness
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Sources for this guide
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Within 5 days of the initial examination, for every occupational injury or illness, according to the form and 8 CCR 14003; 8 CCR 9785 phrases it as 5 working days. Emergency and urgent care physicians also file one after the initial visit, and each new primary treating physician files one. A late report may bring a civil penalty.
DWC runs an Electronic Reporting System for the Doctor's First Report under SB 1160, with an online system and EDI for high-volume filers such as hospitals. Participation is currently a voluntary pilot. A physician who files online with DWC is still responsible for sending a copy to the claims administrator, and DWC plans regulations to phase out paper filing.
No. It is reported with OMFS code WC001, but 8 CCR 9789.14 lists it among reports that are not separately reimbursable because the fee is included in the evaluation and management service for the visit. By contrast, the PR-2 progress report is separately reimbursable under code WC002.
Item 17 asks the patient to describe how the accident or exposure happened, naming the specific object, machinery or chemical. If the patient cannot, the doctor completes it immediately, and the form states that a patient's inability or failure to complete it does not affect his or her rights to workers' compensation under the California Labor Code.