STATE OF CALIFORNIA DWC DISTRICT OFFICE DOCUMENT COVER SHEET Is this a new case? Yes Companion Cases Exist No Walkthrough Yes No More than 15 Companion Cases SSN: Date:(MM/DD/YYYY) Specific Injury Case Number 1 Cumulative Injury (End Date: MM/DD/YYYY) (Start Date: MM/DD/YYYY) (If Specific Injury, use the start date as the specific date of injury) Body Part 1: Body Part 3: Body Part 2: Body Part 4: Other Body Parts: Please check unit to be filed on ( check only one box ) ADJ DEU SIF UEF INT RSU Companion Cases Specific Injury Case Number 2 Cumulative Injury (Start Date: MM/DD/YYYY) (End Date: MM/DD/YYYY) (If Specific Injury, use the start date as the specific date of injury) Body Part 1: Body Part 3: Body Part 2: Body Part 4: Other Body Parts: DWC-CA form 10232.1 Rev. 7/2010 - Page 1 of 8 Specific Injury Case Number 3 Cumulative Injury (Start Date: MM/DD/YYYY) (End Date: MM/DD/YYYY) (If Specific Injury, use the start date as the specific date of injury) Body Part 1: Body Part 3: Body Part 2: Body Part 4: Other Body Parts: Specific Injury Case Number 4 Cumulative Injury (Start Date: MM/DD/YYYY) (End Date: MM/DD/YYYY) (If Specific Injury, use the start date as the specific date of injury) Body Part 1: Body Part 3: Body Part 2: Body Part 4: Other Body Parts: Specific Injury Case Number 5 Cumulative Injury (Start Date: MM/DD/YYYY) (End Date: MM/DD/YYYY) (If Specific Injury, use the start date as the specific date of injury) Body Part 1: Body Part 3: Body Part 2: Body Part 4: Other Body Parts: DWC-CA form 10232.1 Rev. 7/2010- Page 2 of 8 Specific Injury Case Number 6 Cumulative Injury (Start Date: MM/DD/YYYY) (End Date: MM/DD/YYYY) (If Specific Injury, use the start date as the specific date of injury) Body Part 1: Body Part 3: Body Part 2: Body Part 4: Other Body Parts: Specific Injury Case Number 7 Cumulative Injury (Start Date: MM/DD/YYYY) (End Date: MM/DD/YYYY) (If Specific Injury, use the start date as the specific date of injury) Body Part 1: Body Part 3: Body Part 2: Body Part 4: Other Body Parts: Specific Injury Case Number 8 Cumulative Injury (Start Date: MM/DD/YYYY) (End Date: MM/DD/YYYY) (If Specific Injury, use the start date as the specific date of injury) Body Part 1: Body Part 3: Body Part 2: Body Part 4: Other Body Parts: DWC-CA form 10232.1 Rev. 7/2010- Page 3 of 8 Specific Injury Case Number 9 Cumulative Injury (Start Date: MM/DD/YYYY) (End Date: MM/DD/YYYY) (If Specific Injury, use the start date as the specific date of injury) Body Part 1: Body Part 3: Body Part 2: Body Part 4: Other Body Parts: Specific Injury Case Number 10 Cumulative Injury (Start Date: MM/DD/YYYY) (End Date: MM/DD/YYYY) (If Specific Injury, use the start date as the specific date of injury) Body Part 1: Body Part 3: Body Part 2: Body Part 4: Other Body Parts: Specific Injury Case Number 11 Cumulative Injury (Start Date: MM/DD/YYYY) (End Date: MM/DD/YYYY) (If Specific Injury, use the start date as the specific date of injury) Body Part 1: Body Part 3: Body Part 2: Body Part 4: Other Body Parts: DWC-CA form 10232.1 Rev. 7/2010- Page 4 of 8 Specific Injury Case Number 12 Cumulative Injury (Start Date: MM/DD/YYYY) (End Date: MM/DD/YYYY) (If Specific Injury, use the start date as the specific date of injury) Body Part 1: Body Part 3: Body Part 2: Body Part 4: Other Body Parts: Specific Injury Case Number 13 Cumulative Injury (Start Date: MM/DD/YYYY) (End Date: MM/DD/YYYY) (If Specific Injury, use the start date as the specific date of injury) Body Part 1: Body Part 3: Body Part 2: Body Part 4: Other Body Parts: Specific Injury Case Number 14 Cumulative Injury (Start Date: MM/DD/YYYY) (End Date: MM/DD/YYYY) (If Specific Injury, use the start date as the specific date of injury) Body Part 1: Body Part 3: Body Part 2: Body Part 4: Other Body Parts: DWC-CA form 10232.1 Rev. 7/2010- Page 5 of 8 Specific Injury Case Number 15 Cumulative Injury (Start Date: MM/DD/YYYY) (End Date: MM/DD/YYYY) (If Specific Injury, use the start date as the specific date of injury) Body Part 1: Body Part 3: Body Part 2: Body Part 4: Other Body Parts: Specific Injury Case Number 16 Cumulative Injury (Start Date: MM/DD/YYYY) (End Date: MM/DD/YYYY) (If Specific Injury, use the start date as the specific date of injury) Body Part 1: Body Part 3: Body Part 2: Body Part 4: Other Body Parts: DWC-CA form 10232.1 Rev. 7/2010- Page 6 of 8 District office codes for place of venue Legend Abbreviation AHM ANA BAK EUR FRE GOL LAO LBO MDR OAK OXN POM RDG RIV SAC SAL SBR SDO SFO SJO SLO SRO STK VNO Office Anaheim Santa Ana Bakersfield Eureka Fresno Goleta Los Angeles Long Beach Marina del Rey Oakland Oxnard Pomona Redding Riverside Sacramento Salinas San Bernardino San Diego San Francisco San Jose San Luis Obispo Santa Rosa Stockton Van Nuys Use this document to complete forms, but do not file this document with your forms. DWC-CA form 10232.1 Rev. 7/2010 - Page 7 of 8 Body Part Code List The body part codes listed below are used to complete forms that require the listing of the part of the body that is in issue. Please do not file this document with your forms. 100 110 120 121 124 130 140 141 144 145 146 148 149 150 160 198 200 300 310 311 313 315 318 319 320 330 340 398 400 410 411 420 430 440 450 498 Head - not specified Brain Ear - not specified Ear - external Ear - internal including hearing Eye - including optic nerves and vision Face - not specified Jaw - including chin and mandible Mouth - including lips, tongue, throat and taste Teeth Nose - including nasal passages, sinus and smell Face - multiple parts any combination of above parts Face - forehead, cheeks, eyelids Scalp Skull Head - multiple injury any combination of above parts Neck Upper extremities - not specified Arm - above wrist not specified Arm - upper arm humerus Arm - elbow head of radius Arm -forearm radius and ulna Arm - multiple parts any combination of above parts Arm - not specified Wrist Hand - not wrist or fingers Fingers Upper extremities - multiple parts any combination of above parts Trunk - not specified Abdomen - including internal organs and groin Hernia Back - including back muscles, spine and spinal cord Chest - including ribs, breast bone and internal organs of the chest Hips - including pelvis, pelvic organs, tailbone, coccyx and buttocks Shoulders - scapula and clavicle Trunk - use for side; multiple parts any combination of above parts 500 510 511 513 515 518 519 520 530 540 598 700 800 801 802 810 820 830 840 841 842 850 860 870 880 999 Lower extremities - not specified Legs - above ankles, not specified Thigh femur Knee Patella Lower leg tibia and fibula Leg - multiple parts any combination of above parts Leg - not specified Ankle malleolus Foot not ankle or toe Toes Lower extremities - multiple parts any combination of above parts Multiple parts more than five major parts use only in fifth position of listing of body parts Body system - not specific Circulatory system - heart -other than heart attack, blood, arteries,veins, etc. Circulatory system - Heart attack Digestive system - stomach Excretory system - kidneys, bladder, intestines, etc. Musculo-skeletal system - bones, joints, tendons, muscles, etc. Nervous system - not specified Nervous system - stress Nervous system - Psychiatric/psych Respiratory system - lungs, trachea, etc. Skin dermatitis, etc. Reproductive systems Other body systems Unclassified - insufficient information to identify body parts Use this document to complete forms, but do not file this document with your forms. DWC-CA form 10232.1 Rev. 7/2010- Page 8 of 8