Doctor's First Report of Occupational Injury or Illness - Form 5021

Within 5 working days of an injured worker’s initial examination, the Primary Treating Physician shall submit a Doctor's First Report of Occupational Injury or Illness - Form 5021 to the claims administrator.

Frequently Asked Questions:

Q: Do emergency and urgent care physicians also need to submit Form 5021?

A: Yes. Emergency and urgent care physicians, as well as each new Primary Treating Physician, must also submit Form 5021 within 5 working days of the injured worker’s initial examination.

Q: Which version of the form do providers need to use?

A: As of January 1, 2016, providers must use the new 2015 version, revision 5, of the Form 5021, which incorporates ICD-10 diagnosis codes.


California Code of Regulations § 9785(e):

(e)(1) Within 5 working days following initial examination, a primary treating physician shall submit a written report to the claims administrator on the form entitled “Doctor's First Report of Occupational Injury or Illness,” Form DLSR 5021. Emergency and urgent care physicians shall also submit a Form DLSR 5021 to the claims administrator following the initial visit to the treatment facility. On line 24 of the Doctor's First Report, or on the reverse side of the form, the physician shall (A) list methods, frequency, and duration of planned treatment(s), (B) specify planned consultations or referrals, surgery or hospitalization and (C) specify the type, frequency and duration of planned physical medicine services (e.g., physical therapy, manipulation, acupuncture).

(2) Each new primary treating physician shall submit a Form DLSR 5021 following the initial examination in accordance with subdivision (e)(1).

(3) Secondary physicians, physical therapists, and other health care providers to whom the employee is referred shall report to the primary treating physician in the manner required by the primary treating physician.

(4) The primary treating physician shall be responsible for obtaining all of the reports of secondary physicians and shall, unless good cause is shown, within 20 days of receipt of each report incorporate, or comment upon, the findings and opinions of the other physicians in the primary treating physician's report and submit all of the reports to the claims administrator.

Download the New Form 5021

Doctor's first report of occupational injury or illness - Form 5021

The PDF file automatically downloads when you click the link above. Problems? Contact us so we can help.

Doctor's First Report of Occupational Injury or Illness - DWC Form 5021

Additional Information

California Code of Regulations § 9785(e)

DWC Forms Page

DWC ICD-10 page

DIR Newsline No.: 2015-86


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