STATE OF CALIFORNIA DOCTOR'S FIRST REPORT OF OCCUPATIONAL INJURY OR ILLNESS Within 5 days of your initial examination, for every occupational injury or illness, send tow copies of this report to the employer's workers' compensation insurance carrier or the insured employer. Failure to file a timely doctor's report may result in assessment of a civil penalty. In the case of diagnosed or suspected pesticide poisoning, send a copy of the report to Division of Labor Statistics and Research, P.O. Box 420603, San Francisco, CA 94142-0603, and notify your local health officer by telephone within 24 hours. PLEASE DO NOT 1. INSURER NAME AND ADDRESS USE THIS COLUMN Case No. 2. EMPLOYER NAME 3. Address No. and Street City Industry Zip County 4. Nature of business (e.g., food manufacturing, building construction, retailer of women's clothes.) 5. PATIENT NAME (first name, middle initial, last name) 8. Address: No. and Street City 6. Sex • Male 7. Date of Mo. • Female Birth 9. Telephone number ( ) 11. Social Security Number County Zip 10. Occupation (Specific job title) 12. Injured at: No. and Street City Day Age Yr. Hazard Disease Hospitalization Occupation 13. Date and hour of injury Mo. Day Yr. Hour 14. Date last worked Mo. Day Yr. or onset of illness a.m. p.m. Return Date/Code 15. Date and hour of first Mo. Day Yr. Hour 16. Have you (or your office) previously examination or treatment a.m. p.m. treated patient? • Yes • No Patient please complete this portion, if able to do so. Otherwise, doctor please complete immediately, inability or failure of a patient to complete this portion shall not affect his/her rights to workers' compensation under the California Labor Code. 17. DESCRIBE HOW THE ACCIDENT OR EXPOSURE HAPPENED. (Give specific object, machinery or chemical. Use reverse side if more space is required.) 18. SUBJECTIVE COMPLAINTS (Describe fully. Use reverse side if more space is required.) 19. OBJECTIVE FINDINGS (Use reverse side if more space is required.) A. Physical examination B. X-ray and laboratory results (State if non or pending.) 20. DIAGNOSIS (if occupational illness specify etiologic agent and duration of exposure.) Chemical or toxic compounds involved? • Yes • No ICD-9 Code ___ ___ ___ - ___ ___ 21. Are your findings and diagnosis consistent with patient's account of injury or onset of illness? • Yes • No If "no", please explain. 22. Is there any other current condition that will impede or delay patient's recovery? • Yes • No If "yes", please explain. 23. TREATMENT RENDERED (Use reverse side if more space is required.) 24. If further treatment required, specify treatment plan/estimated duration. 25. If hospitalized as inpatient, give hospital name and location Date admitted 26. WORK STATUS -- Is patient able to perform usual work? • Yes • No If "no", date when patient can return to: Regular work ____/____/____ Modified work ____/____/____ Mo. Day Yr. Estimated stay Specify restrictions ______________________________________________ Doctor's Signature ______________________________________________________ CA License Number ________________________________ Doctor Name and Degree (please type) ______________________________________ IRS Number ________________________________ Address _______________________________________________________________ Telephone Number (_____)__________________________ FORM 5021 (Rev. 4) 1992 Any person who makes or causes to be made any knowingly false or fraudulent material statement or material representation for the purpose of obtaining or denying workers' compensation benefits or payments is guilty of a felony. 2002 © American LegalNet, Inc.