- Workers Compensation Inclusion/Exclusion Form - Minnesota
- Employer's First Report of Injury or Occupational Disease - Alabama
- Workers' Compensation Commission Application for Ajustment Claim - Illinois
- Workers' Compensation Claim Form - California
- Employer's First Report of Injury or Disease - Wisconsin
- Worker's Report of Injury - Arizona
Fillable Printable Texas Workers' Compensation Work Status Report
Fillable Printable Texas Workers' Compensation Work Status Report
Texas Workers' Compensation Work Status Report
Employee - You are required to report your injury to your employer within 30 days if
your employer has workers’ compensation insurance. You have the right to free
assistance from the Texas Department of Insurance, Division of Workers’
Compensation and may be entitled to certain medical and income benefits. For
further information call
y
our local Division field office or 1
(
800
)
-252-7031.
DWC FORM-73 (Rev. 02/11) Page 1 DIVISION OF WORKERS’ COMPENSATION
TEXAS WORKERS’ COMPENSATION WORK STATUS REPORT
Empleado - Es necesario que reporte su lesión a su empleador dentro de 30 días a partir de la
fecha en que se lesionó si es que su empleador cuenta con un seguro de compensación para
trabajadores. Usted tiene derecho a recibir asistencia gratuita por parte de la División de
Compensación para Trabajadores, y también puede tener derecho a ciertos beneficios médicos y
monetarios. Para mayor información comuníquese con la oficina local de la División al teléfono
1-800-252-7031.
PART I: GENERAL INFORMATION
5. Doctor's Name and Degree
(for transmission purposes only) Date Being Sent
1. Injured Employee's Name
6. Clinic/Facility Name
9. Employer's Name
2. Date of Injury
3. Social Security Number (last
4)
xxx-xx-
7. Clinic/Facility/Doctor Phone & Fax
10. Employer’s Fax # or Email Address (if known)
4. Employee’s Description of Injury/Accident
8. Clinic/Facility/Doctor Address (street address)
11. Insurance Carrier
City
State
Zip
12. Carrier’s Fax # or Email Address (if known)
PART II: WORK STATUS INFORMATION (FULLY COMPLETE ONE INCLUDING ESTIM ATED DATES AND DESCRIPTION IN 13(c) AS APPLICABLE)
13. The injured employee’s medical condition resulting from the workers’ compensation injury:
(a) will allow the employee to return to work as of (date) without restrictions.
(b) will allow the employee to return to work as of (date) with the restrictions identified in P ART III, which are expected to last
through
(date).
(c) has prevented and still prevents the employee from returning to work as of
(date) and is expected to continue through (date).
The following describes how this injury prevents the employee from returning to work:
PART III: ACTIVITY RESTRICTIONS* (ONLY COMPLETE IF BOX 13(b) IS CHECKED)
14. POSTURE RESTRICTIONS (if any): 17. MOTION RESTRICTIONS (if any):
19. MISC. RESTRICTIONS
(if any):
Max Hours per day: 0 2 4 6 8 Other Max Hours per day: 0 2 4 6 8 Other
Max hours per day of work:
Standing Walking
Sit/Stretch breaks of per
Sitting Climbing stairs/ladders
Must wear splint/cast at work
Kneeling/Squatting
Grasping/Squeezing
Must use crutches at all times
Bending/Stooping Wrist flexion/extension
No driving/operating heavy equipment
Pushing/Pulling Reaching
Can only drive automatic transmission
Twisting Overhead Reaching
No work / hours/day work:
in extreme hot/cold environments
at heights or on scaffolding
Other:
Keyboarding
Must keep elevated clean & dry
15. RESTRICTIONS SPECIFIC TO (if applicable):
Other:
No skin contact with:
Left Hand/Wrist
Right Hand/Wrist
Left Arm
Right Arm
Neck
Left Leg
Right Leg
Back
Left Foot/Ankle
Right Foot/Ankle
18. LIFT/CARRY RESTRICTIONS (if any):
May not lift/carry objects more than lbs.
for more than
hours per day
May not perform any lifting/carrying
Dressing changes necessary at work
No running
20. MEDICATION RESTRICTIONS (if any):
Must take prescription medication(s)
Advised to take over-the-counter meds
Medication may make drowsy (possible
safety/driving issues)
Other:
Other:
16. OTHER RESTRICTIONS (if any):
* These restrictions are based on the doctor’s best understanding of the employee’s essential job functions. If a particular restriction does not apply, it should be disregarded. If modified duty that
meets these restrictions is not available, the patient should be considered to be off work. Note - these restrictions should be followed outside of work as well as at work.
PART IV: TREATMENT/FOLLOW-UP APPOINTMENT INFORM ATION
21. Work Injury Diagnosis
Information:
22. Expected Follow-up Services Include:
Evaluation by the treating doctor on (date) at : am/pm
Referral to/Consult with on (date) at : am/pm
Physical medicine X per week for weeks starting on (date) at : am/pm
Special studies (list): on (date) at : am/pm
None. This is the last scheduled visit for this problem. At this time, no further medical care is anticipated.
Date / Time of Visit
EMPLOYEE’S SIGNATURE DOCTOR’S SIGNATURE Visit Type:
Initial
Follow-up
Role of Doctor:
Designated doctor
Treating doctor
Referral doctor
Consulting doctor
Carrier-selected RME
DWC-selected RME
Other doctor
Discharge Time
DWC FORM-73 (Rev. 02/11) Page 2 DIVISION OF WORKERS’ COMPENSATION
Frequently Asked Questions
Work Status Report (DWC Form-073)
Under what circumstances am I required to file the DWC Form-073?
Filing requirements for DWC Form-073 vary depending on the type of doctor filing the Work Status Report. The specific
requirements are shown in the chart below.
Type of Doctor When to File DWC Form-073 Where to File Delivery Method Deadline
Treating Doctor
or
Referral Doctor
• after the initial examination of the injured
employee, regardless of the employee’s work
status
• when there is a change in the injured employee’s
work status
• when there is a substantial change in the injured
employee’s activity restrictions
• on a schedule requested by the insurance carrier
as long as it is based on the injured employee’s
scheduled appointments with the doctor (not to
exceed one report every two weeks)
•
injured employee
hand deliver
at the time of
the examination
•
insurance carrier
fax or e-mail
within 2 working
days of the
examination
•
employer
fax or e-mail unless
recipient has not provided
these numbers; then by
personal delivery or mail
• after receiving a set of functional job descriptions,
from the employer or insurance carrier listing
modified duty positions, including the physical and
time requirements of the positions, that the
employer has available for the injured employee
to work
• after receiving a DWC Form-073 from a RME
Doctor that indicates the injured employee is able
to return to work with or without restrictions
•
injured employee
hand deliver unless no
appointment is scheduled
before deadline; then fax
or e-mail unless recipient
has not provided these
numbers; then by mail
within 7 days of
receiving job
description or
RME opinion
•
insurance carrier
• employer
fax or e-mail
Designated Doctor
• after examination of an injured employee to
address any question relating to return to work
NOTE: The Designated Doctor must file a narrative
report along with the DWC Form-073.
•
injured employee
• injured employee’s
representative (if any)
fax or e-mail unless
recipient has not provided
these numbers; then by
other verifiable means
within 7
working days
of the
examination
•
insurance carrier
• treating doctor
fax or e-mail
•
TDI-DWC
fax to 512-490-1047
RME Doctor
selected by
insurance carrier
• after examination of an injured employee
(subsequent to a Designated Doctor's
examination), if the RME doctor determines that
the injured employee can return to work
immediately with or without restrictions
•
injured employee
• injured employee’s
representative (if any)
fax or e-mail unless
recipient has not provided
these numbers; then by
other verifiable means
within 7 days of
the examination
•
insurance carrier
• treating doctor
fax or e-mail
RME Doctor
selected by DWC
Not applicable. TDI-DWC’s medical examinations are ordered in accordance with §408.0041, Texas Labor Code, and applicable
Division of Workers’ Compensation rules.
Where can I find more information about th e DWC Form-073?
For complete requirements regarding the filing of this report, see 28 TAC §§126.6, 127.10, and 129.5. These rules are available
on the TDI website at www.tdi.texas.gov/
wc/rules/index.html
. If you have additional questions, call Comp Connection for Health
Care Providers at 1-800-372-7713 (804-4000 in the Austin area) and select option 3.
NOTE: With few exceptions, upon your request, you are entitled to be informed about information TDI-DWC collects about you;
receive and review the information (Government Code, §§552.021 and 552.023); and have TDI-DWC correct information that is
incorrect (Government Code, §559.004).
