Doctors First Report Of Occupational Injury Or Illness {DLSR 5021}

Form 5021 - DOCTOR'S FIRST REPORT OF OCCUPATIONAL INJURY OR ILLNESS. This is a mandatory California reporting form that treating physicians must submit within five days of the initial examination for any work-related injury or illness. The form collects critical information about the employer, insurer, patient, circumstances of the injury, clinical findings, diagnoses (including ICD-10 codes), and treatment provided. It also documents work status, hospitalization details, and anticipated recovery factors. Page 1 requires patient and incident information, page 2 covers diagnoses, treatment, and work restrictions, and page 3 includes the physician’s declaration under penalty of perjury. Special reporting rules apply for suspected or diagnosed pesticide poisoning, including notifying local health authorities. Failure to file promptly may result in civil penalties. www.FormsWorkflow.com