Find your state's first report, work status and impairment forms, or the federal OWCP forms, with who completes each one and where it goes.
Workers' compensation runs state by state, and the Department of Labor's OWCP covers federal employees, longshore and harbor workers, coal miners and energy employees. Each system has its own first report and progress forms. Among the forms clinicians fill most are California's Doctor's First Report (Form 5021) and PR-2 progress report, the Texas Work Status Report (DWC073), Florida's Uniform Medical Treatment/Status Reporting Form (DWC-25) and the federal Duty Status Report (CA-17).
States with a hub of their own, such as California, New York, Ohio and Washington, link from this page, as does the federal OWCP hub. Below them are the states without a hub, from Alaska's Physician's Report (07-6102) to Wisconsin's WKC-16 series. Deadlines are short: Maryland wants the SF-2 Surgeon's Report within 72 hours through its online form, and Maine's M-1 is due within 5 business days of the exam. Rhode Island's MAB01 affidavit is filed as a notarized original. Spanish versions exist for 21 forms.
Federal
California
Form 5021Doctor's First Report of Occupational Injury or IllnessDWC Form PR-2Primary Treating Physician's Progress Report (PR-2)DWC Form RFARequest for AuthorizationColorado
Nevada
New York
Ohio
Oregon
Pennsylvania
Vermont
Washington
F207-028-000Provider's Initial Report (PIR)F242-130-000Report of Accident (ROA) Workplace Injury, Accident or Occupational DiseaseF242-385-000Activity Prescription Form (APF)West Virginia
07-6102Initial, progress and treatment-plan report from the treating physician on diagnosis, work-relatedness, medical stability, permanent impairment rating and release to regular or modified work.
Physician's report of treatment, diagnosis and causation that the Alaska Commercial Fishermen's Fund requires before approving benefit payments or provider bills for a commercial fisherman's injury.
07-6177Documents the baseline lung, heart and cancer-screening examination a firefighter needs to qualify for the workers' compensation occupational-disease presumption under AS 23.30.121.
Treating physician's first, progress or final report of the injury, diagnosis, treatment, prognosis and date of release from treatment for an Arkansas workers' compensation claim.
Attending provider's report of the employee's medical status and work capacity (full, restricted or no work) for the employer and insurer.
Connecticut-licensed physician's rating of the percentage of permanent loss or loss of use of a body part at maximum medical improvement, used to set specific (permanency) benefits.
Required report of the employee's condition and limitations (diagnosis, safe work capacities, modified/full-duty release) from the provider most responsible for treatment under 19 Del. C. 2322E.
Prescriber's justification and certification that lets a pharmacist dispense a non-preferred or brand-name drug outside the Delaware workers' compensation preferred drug list.
Form No. 12 DCWCAttending physician's report of the accident history, diagnosis, treatment, prior impairment, expected length of disability and return-to-work date for a private-sector DC workers' compensation claim.
Reports work-relatedness, major contributing cause, diagnosis, treatment plan and authorization requests, functional limitations/restrictions, and MMI/permanent impairment rating for an injured worker.
Written expert medical opinion on disputed medical issues (conflicting provider opinions, health care services, reimbursement disputes) for a Judge of Compensation Claims or the Division under s. 440.13(9), F.S.
WC-20aInitial, interim or final physician report of history, findings, diagnosis, treatment, prognosis, return-to-work status/restrictions, maximum recovery date and any permanent disability rating (AMA Guides).
Lets an authorized medical provider request advance authorization of treatment or testing; the insurer must respond within 5 business days or the request stands pre-approved.
WC-240aDescribes the physical demands of an offered job so the authorized treating physician can approve or disapprove it as suitable employment before a WC-240 offer.
Attending physician's standardized treatment plan (diagnosis, modalities, frequency, measurable goals, cost estimate) that the employer/carrier approves or denies before treatment proceeds.
Attending physician's initial and interim report to the employer/carrier and DCD on the injury, diagnosis, treatment and work status.
Patient-prescriber informed consent required before long-term opioid prescribing, which DCD lists among workers' compensation forms.
Physician's written impairment rating for permanent partial disability using the current AMA Guides, with measurements such as loss of range of motion, strength and measured atrophy; one of five factors the Commission weighs.
Report of an employer-requested independent medical examination of the injured worker under Section 12 of the Workers' Compensation Act.
State Form 2118Attending physician's or independent medical examiner's report of examination findings (page 1) and permanent partial impairment rating (page 2).
K-WC-R 87-7Medical manager's report closing a medical-management (case management) file, stating the reason (return to work, release with or without restrictions, carrier request, vocational referral) and certifying the job is within the worker's medical restrictions.
Physician's litigation medical report used by administrative law judges: history, examination, testing, diagnosis, causation, AMA Guides whole-person impairment, MMI date and restrictions for injury, hearing loss or psychological claims.
Form 108-ODPhysician's litigation report for occupational-disease claims (including pneumoconiosis and other lung or heart disease): history, exposure, examination, ILO-classified x-rays and testing, diagnosis, causation, AMA Guides impairment and restrictions.
Form 113Names the employee's designated physician, who coordinates all work-injury care and referrals, and records the physician's acceptance and the employee's medical-information release.
Physician's opinion on whether continued medical treatment is reasonably necessary for the work injury or occupational disease, supporting an application to continue medical benefits beyond the statutory cut-off.
Health care provider's request for prior authorization of treatment or testing under the Louisiana Medical Treatment Schedule, with the carrier's approval, modification or denial on the same form.
Asks the OWCA Medical Director to review a denied, modified or deemed-denied 1010 request, or to grant a variance from the Medical Treatment Schedule.
LWC-WC 1010ACarrier's first request for missing minimum information on an authorization request, with a section for the health care provider's response.
Reports the diagnosis, causation opinion, treatment plan and work capacity (regular, modified or none, with restrictions) of an injured worker at the initial, progress and final visits.
SF-2Treating physician/surgeon's first, progress and final report on the injury, diagnosis, causation, pre-existing conditions, disability and permanent defect.
DIA-appointed impartial physician's report on medical end result, permanent impairment, extent and duration of disability, and whether the work injury is the major or predominant cause.
WC-728Diagram on which the operating surgeon marks and certifies the exact point of amputation (and distance below elbow or knee for arm/leg) for specific-loss benefits.
Narrative medical report on diagnosis, causation, treatment, restrictions, maximum medical improvement (MMI) and permanent partial disability (PPD) rating, as requested by the insurer.
Reports whether the injured employee can work without restrictions, with restrictions, or not at all, and the dates, after each visit.
Optional model agreement between prescriber and injured worker required before long-term opioid treatment under Minnesota's workers' compensation treatment parameters.
Treating physician's report of treatment, surgery, referrals, return-to-work status and restrictions, and any disability rating, with a brief narrative at the final report.
Required physician report for any eye injury resulting in permanent disability, recording acuity, fields and other data to compute the loss of vision.
Attending physician's information on physical rehabilitation received or expected, used by the Division to decide eligibility for physical rehabilitation benefits.
Formulario de Estado Médico
Documents the injured worker's current work capacity (full, modified, limited hours or off work), activity and lifting capacities, MMI/impairment status and follow-up after each visit, to support stay-at-work/return-to-work planning.
Treating physician's referral establishing the need, services, hours, expected duration and physician oversight of domiciliary (home attendant) care for an injured worker.
Health professional's report at every visit of diagnosis, causation, treatment plan, work capability and restrictions, MMI and permanent impairment, supporting temporary alternative work under RSA 281-A:23-b.
Physician certifies a worker's preexisting permanent impairment, the subsequent work injury and whether the combination causes greater disability (or death), supporting an insurer's Second Injury Fund reimbursement claim (RSA 281-A:54).
Physician report stating the medical diagnosis (and need for treatment or temporary disability) attached to a motion for medical and/or temporary benefits.
Physician statement of the petitioner's need for emergent medical care, that delay will cause irreparable harm, and the specific nature of that harm, required to support a WC-383 motion.
Gives a quantitative description of claim-related physical restrictions, work status, diagnosis work-relatedness and MMI so the employer can offer safe return-to-work activities.
Standard questionnaire a party sends to the treating provider asking for diagnosis, causation, MMI, impairment rating, FCE, work and activity restrictions and referrals, answered to a reasonable medical probability.
Asks the WCA Medical Cost Containment Bureau to conduct utilization review of disputed medical care on a claim.
Physician's report of whether the claimant is released to regular or modified work or remains temporarily totally disabled, with specific restrictions and need for continuing medical maintenance or vocational rehabilitation.
Sworn physician statement at 10, 20 or 30 days (or other interval) of incapacity covering ongoing treatment, expected discharge, ability to return to former or other work, restrictions and MMI.
WCC Form 14BTreating or evaluating physician's statement of diagnosis, MMI date, permanent impairment ratings, permanent limitations, retained hardware and future medical care needs, used in settlement and hearings.
DOL-LM-112Records the exact point of finger amputation on a hand diagram so the insurer can compute the scheduled loss under SDCL 62-4-6.
Treating physician's report of the injury account, findings, diagnosis and causation, treatment, disability periods (light duty/regular work), permanent defect and MMI.
Treating physician marks the exact point of amputation of the hand/fingers/metacarpals or foot/toes/metatarsals with a straight line to support a scheduled-loss claim.
Certified medical opinion on causation, disability and permanency used as evidence at a worker's compensation hearing instead of live testimony.
Treating practitioner's report of diagnosis, treatment, temporary disability period and permanent disability rating for a claim with more than 3 weeks of disability or permanent disability.
Physician's report of visual acuity and field loss for determining permanent disability from an eye injury under DWD 80.26.
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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It depends on the state. California uses the Doctor's First Report (Form 5021), Nevada the C-4, Oregon the 827, Utah Form 123, Washington the Report of Accident (F242-130-000) and Ohio the treating provider's block on the FROI. In Alaska, Maine and Maryland one form covers the first visit and later ones: the Physician's Report (07-6102), the M-1 and the SF-2. For a federal employee's traumatic injury, the attending physician reports on the back of the CA-16.
Deadlines vary by state. Maryland's SF-2 and Oregon's 827 are due within 72 hours, Nevada's C-4 within 3 working days, and California's Form 5021 and Washington's Report of Accident within 5 days. Utah's Form 123 is due within 7 days, Pennsylvania's LIBC-9 within 10 days of starting treatment and the DC Form 12 within 20 days. Texas wants the DWC073 work status report within 2 working days of the exam.
It depends on the state's fee schedule. California bills the PR-2 under OMFS code WC002, while the Form 5021 is included in the visit. North Carolina lets providers charge up to the fee schedule amount for CPT 99080 for the Medical Status Questionnaire. New Mexico pays for the Provider's Report of Physical Ability only at the first assessment or when work status changes. Pennsylvania bars charges for documentation that supports a bill.
Some are. Spanish versions exist for 21 of the workers' comp forms here, including the federal CA-17, CA-20 and OWCP-5 work capacity evaluations, the Texas DWC073, Oregon's 827, Montana's Medical Status Form and Wisconsin's WKC-16-B-E. California's Form 5021 has no Spanish version, though its Notice of Predesignation of Personal Physician (DWC Form 9783) does.