11. Will the injury result in permanent restriction, total or partial loss of function or 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 Yes-Describe
12. Is employee working? 13. When do you estimate employee can
Yes No
a. Resume limited work of any kind? b. Resume regular work?
Date (mm/dd/yyyy) Date (mm/dd/yyyy)
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 No
16. Is rehabilitation treatment or service or evaluation
recommended?
17. If rehabilitation treatment or services or evaluation is recommended, has referral
been made?
18. Remarks 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
The Privacy Act of 1974, as amended (5 U.S.C. 552a) section 901 of Title 33 to the US Code and 33 U.S.C. 907 (b) authorize collection of this
information. The purpose of this information is to determine an injured worker's entitlement to compensation and medical benefits under the
Longshore and Harbor Workers' Compensation Act (LHWCA). Completion of this form is not mandatory; however, failure to provide the information
may result in the loss of compensation benefits. Additional disclosures of this information may be to: (1) the employer which employed the claimant at
the time of injury, or to the insurance carrier or other entity which secured the employer's compensation liability. (2) physicians and other medical
service providers for use in providing treatment or medical/vocational rehabilitation, making evaluations and for other purposes relating to the medical
management of the claim. (3) the Department of Labor's Office of Administrative Law Judges (OALJ), or other person, board or organization, which is
authorized or required to render decisions with respect to the claim or other matter arising in connection with the claim. (4) Federal, state and local
agencies for law enforcement purposes, to obtain information relevant to a decision under the LHWCA to determine whether benefits are being and
have been paid properly, and where appropriate, to pursue salary/administrative offset and debt collection actions required or permitted by law. (5)
Failure to disclose all requested information may delay the processing of the claim, the payment of benefits, or may result in an unfavorable decision
or reduced level of benefits.
PRIVACY ACT STATEMENT
23. Telephone No. (Area Code) 24. Date of Report
DO NOT SEND COMPLETED FORMS TO THIS OFFICE.
Public Burden Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a
valid OMB control number. Public reporting burden for this collection of information is estimated to average 30 minutes per response, including time
for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of
information. Use of this form is optional, however furnishing the information is required in order to obtain and/or retain benefits. (33 U.S.C. 907 6).
Send comments regarding this burden estimate or any aspect of this collection of information, including suggestions for reducing this burden, to the U.
S. Department of Labor, 200 Constitution Avenue, NW, Room C-4315, Washington, D.C. 20210, and reference the OMB Control Number.
14. If employee is unable to do his/her regular work, but can do limited work, specify work limitations due to this injury.
Yes- Explain No- Explain Yes- To whom? No- Explain
