Wisconsin's Worker's Compensation Division uses this report to determine permanent disability from an eye injury under its loss-of-vision rule, DWD 80.26. The physician records history, diagnosis, cataract and surgery questions, distance and near acuity with and without correction (after injury and pre-existing), binocular vision and diplopia, field loss on charts, other ocular disabilities and the return-to-work date.
The examining physician, often an ophthalmologist or optometrist, completes the whole form and signs it in their own handwriting.
Download the current version from the source each time; forms change without notice.
Physician's Report on Eye Injuries
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.
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.
Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.
DWD's form page says the insurer or self-insured employer files it when temporary disability lasts beyond 3 weeks or permanent disability results. DWD's medical report guidance also calls for a report when a worker had eye treatment three or more times outside the workplace, and says eye injuries are reported on WKC-16-A.
The print form says the doctor's signature is required in the doctor's own handwriting. DWD offers a Word version for filling in the content on a computer, but the signature line on the form still calls for a handwritten signature and the date signed.