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Delaware Physician's Report of Workers' Comp Injury

Delaware law, 19 Del. C. 2322E, requires the provider most responsible for treating a work injury to report the employee's condition and limitations on this form. It covers diagnosis, treatment plan, hours per day the patient can work, DOT work classification from sedentary to very heavy, positional tolerances, whether limits are temporary or permanent, and modified or full duty release dates.

Who completes it

The health care provider most responsible for treatment completes and signs it, noting whether they are a Certified Provider. The injured worker's description of the accident is recorded at the initial visit.

Submitting and payment

How to submit it
Complete it no later than 10 days after the first evaluation or treatment, and again for progress and closing reports, and send copies to the employee, the employer and the insurer.
Who pays
The form does not address fees.

Good to know

  • Mark 'Progress' when any material change in physical capability affects return to work status, and 'Closing' when the worker is discharged from care.
  • Office notes and records do not replace the form; an electronically generated version is allowed only if it contains every item the form requires.
  • Positional tolerances cover sitting, standing, walking, driving, bending, kneeling, squatting, climbing, repeated arm motions, wrist and hand use, overhead reaching and foot controls.
  • Occasional means up to one-third of the time, frequent one-third to two-thirds, and constant two-thirds or more. The form is revised 03/2011.

Get the official form

Download the current version from the source each time; forms change without notice.

Physician's Report of Worker's Compensation Injury

Official pagePDF

Fill it with Vero

If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.

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How this list is checked

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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Frequently asked questions

What is the deadline for the Delaware Physician's Form?

Under 19 Del. C. 2322E(b), the provider most responsible for treatment must submit it as quickly as possible and no later than 10 days after the first evaluation or treatment, and give copies to the employee, the employer and the insurer, if any.

Can my office notes replace the Delaware physician's report?

No. The instructions say office notes and records do not replace the form. A physician may generate the information electronically, but the submission must contain every item specific to the injury that the Physician's Form asks for.

What work classifications does the Delaware form use?

DOT classifications: sedentary (up to 10 pounds occasionally), light (up to 20 pounds occasionally), medium (20 to 50), heavy (50 to 100) and very heavy (over 100), each with frequent and constant force limits. The provider circles one and the hours per day the patient can work.