In litigated Wisconsin worker's compensation claims, this certified practitioner report stands in for live medical testimony. Filed for either the employee or the employer and insurer, it gives the history, diagnosis, treatment dates, causation opinion, disability dates, permanent disability percentages and prognosis. Under section 102.17(1)(d) of the Wisconsin Statutes, certified reports filed in time are prima facie evidence of their contents.
The treating or examining practitioner completes and signs it under a certification subject to penalties under section 943.39 of the Wisconsin Statutes, stating licensure and where they practice. A complete copy of the medical history or notes can stand in for some narrative items.
Download the current version from the source each time; forms change without notice.
Practitioner's Report on Accident or Industrial Disease in Lieu of Testimony
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.
Litigation. DWD describes it as the form used when an injured worker has applied for a hearing, letting the parties obtain competent medical testimony without the practitioner appearing. Certified reports are prima facie evidence under section 102.17(1)(d) of the Wisconsin Statutes if they are filed in time.
The report must be filed with the department and the other parties 15 days before the hearing date to be accepted as evidence. If it is not filed in time, the doctor must be produced to give oral testimony at the hearing.
The treating or examining practitioner, such as a physician, chiropractor, psychologist, podiatrist, dentist, physician assistant or advanced practice nurse prescriber. The form asks whether the practitioner is licensed and practicing in Wisconsin and, if not, where they are licensed and practicing.