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

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

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).

(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:

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

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).