Attending Physician's Supplementary Report U.S. Department of Labor (Longshore and Harbor Workers' Compensation Act, as extended) Employment Standards Administration Office of Workers' Compensation Programs INSTRUCTIONS: Use this form to make progress reports and to make a final report when the patient is discharged. Progress reports should be submitted about every thirty days, the original to the District Director (See item 19. on reverse) and one copy to the insurance carrier or self-insured employer. Please answer all questions fully. If a question is not applicable, enter "NA". The exact point of amputation or other permanent partial impairment must be known to determine compensation the injured is entitled to receive. If preferred, physician may submit a narrative report covering all information requested on this form. Use "Remarks" on reverse of form if more space is needed for any answer. 1. Type of report (Mark X one) Progress OMB No. 1215-0160 FOR OFFICE USE OWCP No. Carrier's No. 2. Date of Injury (Month, day, year) Final 3. Name of injured employee (First, M.I., last) 4. Employee's home address (No., St., City, State, Zip) 5. Name of employer 6. Name of insurance carrier 7a. Have you filed a previous report giving history? Yes - Skip to item 8 7b. State how injury occurred and give source of information. (If claim is for occupational disease, include occupational history and date of onset of related symptoms) No - Answer 7b and 7c 7c. Was employee previously under the care of another physician for this injury? No Yes - Give physician's name and address and reason for transfer 8. Is there any history or evidence of pre-existing injury, disease or physical impairment? 9a. Present condition (include diagnosis, subjective complaints, objective findings, and any changes of condition since last report.) 9b. If employee was hospitalized since last report, indicate and give name and address of hospital. This report is authorized by 33 U.S.C. 907(b). While you are not required to respond on this form, your cooperation is needed to insure that the injured worker's compensation case is properly processed by the U.S. Department of Labor. This form is used to request medical information which will be used to determine an injured worker's entitlement to compensation and medical benefits. Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number. Rev. May 1998 2002 © American LegalNet, 10a. Describe treatment provided 10b. Date of first treatment 10c. Date of most recent treatment 10e. Are you continuing treatment? 10d. Has treatment been terminated? 10f. If treatment is continuing estimate probable duration No Yes 11. No Will the injury result in permanent restriction, total or partial loss of function of a part or member, or permanent disfigurement of the head, face, or neck, or some other part of the body which will handicap the employee in securing or maintaining employment? No 12. Yes - Indicate reason Yes - Describe Is employee working? Yes 13. When do you estimate employee can No a. Resume limited work of any kind Date b. Resume regular work Date 14. If employee is unable to do his/her regular work, but can do limited work, specify work limitations due to this injury. 15. In your opinion, was the occurrence described above (or in the previous report which gave this information) the competent producing cause of the injury and disability? Yes 16. No Is rehabilitation treatment or services or evaluation recommended? Yes - Explain No - Explain 18. Remarks 17. If rehabilitation treatment or services or evaluation is recommended, has referral been made? Yes - To whom No - Explain 19. Send the original of your report to: Office of the District Director U.S. Department of Labor Office of Workers' Compensation Programs 20. Name of attending physician (Type or print) 21. Signature of physician 22. Address (No., St., City, State, Zip code) 23. Telephone No. (Area code) 24. Date of report Public Burden Statement We estimate that it will take an average of 30 minutes to complete this collection of information, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. If you have any comments regarding these estimates or any other aspect of this collection of information, including suggestions for reducing this burden, send them to the U.S. Department of Labor, Division of Longshore and Harbor Workers' Compensation, 200 Constitution Avenue, N.W., Washington, D.C. 20210. DO NOT SEND THE COMPLETED FORM TO THIS OFFICE 2002 © American LegalNet, Inc.