THE GOVERNMENT OF THE DISTRICT OF COLUMBIADEPARTMENT OF EMPLOYMENT SERVICESOFFICE OF WORKERS222 COMPENSATIONWASHINGTON, DC 2001(202) 671-1000 IMPORTANT 226 THIS REPORT SHALL BE FILED IMMEDIATELY. FAILURE TO COMPLY WITHIN TWENTY (20) DAYS CAN RESULT IN UN-NECESSARY DELAY IN PAYMENT OF BENEFITS TO THE INJURED WORKER AND PAYMENT FOR SERVICES RENDERED. (sec. 8, d)EMPLOYEE EMPLOYER CARRIER PHYSICIAN (Name)(Name)(Name)(Name)(Age)(Sex)(Soc. Sec. No.)(Address)(Address)(Address)(Identi037cation No.)(Policy No.)(Specialty)(Tel. No.)FOR USE OF PHYSICIAN Accident1. Date of accident: 2. Time :AM/PM3. Date disability began: 4. State where and how the accident occurred as described by patient: Injury5. Give diagnosis of injury or disease: 6. Will the injury result in a permanent defect? 7. If so, what? 8. Has the patient any physical impairment due to previous injury or disease? If so, what? 9. State physical limitations, if any: 10. In your opinion is the injury and disability as a result of the accident described in (4) above? Yes NoTreatment11. Date of your 037rst treatment: 12. Describe: 13. Who engaged your services? 14. Were X-Rays taken? Yes No15. When? 16. Where? 17. X-Ray diagnosis: 18. Did anyone else treat the patient? Yes No 19. If so, who? 20. When? 21. Hospital, if any? 22. Admission Date: 23. Discharge Date:24. If further treatment needed? Yes No 25. How long? Disability26. Will the patient ever be able to resume their regular occupation? Yes No27. Expected length of disability? 2 weeks 1 month 3 months 6 months or longer Unknown28. Patient was or will be able to resume regular work on: 30. Date of death, if any? Physician222s IRS Number Physician222s Signature DateForm No. 12 DCWCDate of 036is Report: Employee Social Security No. Employer Identi037cation No. Insurer No. MEDICAL REPORT American LegalNet, Inc. www.FormsWorkFlow.com