Utah requires the treating physician to file this first report for work injuries or occupational diseases that involve lost time or medical treatment. It captures the employee's own account of how the injury happened, the diagnosis with an ICD code, whether the condition results from the described work injury or exposure, and whether the employee needs an interpreter. Rule R612-100-3(H) of the Utah Administrative Code requires it.
The treating physician completes the whole form, including the employee's statement of cause written in the first person. The employer and carrier file their own first reports on Forms 122E and 122C.
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Physician's Initial Report of Work Injury or Occupational Disease
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Within 7 days of the initial visit. The physician sends the carrier a copy with the bill and progress reports, and sends copies of the form alone to the injured employee, the employer and the Utah Labor Commission, which accepts it by fax or online through Easy Online 123.
Yes. Item 20 asks whether the condition requiring treatment results from the industrial injury or exposure described and offers yes, no or undetermined. The report is required for claims with lost time or medical treatment, so it is filed even while the work relationship is still being sorted out.