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                      DOCTOR'S FIRST REPORT OF OCCUPATIONAL INJURY OR ILLNESS 
Within 5 days of your initial examination, for every occupational injury or illness, send two copies of this report to the 
employer's workers' compensation insurance carrier or the insured employer. Failure to file a timely doctor's report may 
result in assessment of a civil penalty. In the case of diagnosed or suspected pesticide poisoning, send a copy of the report 
to Department of Industrial Relations, P.O. Box 420603, San Francisco, CA 94142-0603, and notify your local health 
officer by telephone within 24 hours. 
1. Insurer Name and Address 

2. Employer Name 

3.  Address           No. and Street                                     City                        Zip Code 

4. Nature of business (e.g. food manufacturing, building construction, retailer of women's clothes.) 

5. Patient Name  (first Name,  middle initial  , last name)              6. Sex                      7. Date of Birth 
                                                                          
8.  Address           No. and Street                       City                 Zip Code             9.Phone Number 

10. Occupation (Specific job title)  11.  Social Security Number         12. Address No.& Street Where Inj. Occurred 

City Where Injury Occ.     County          13. Date and hour of injury or onset of illness 

14. Date last worked       15. Date and hour of 1st exam or treatment 16. Have you or your office previously rendered treatment 

Patient please complete this portion, if able to do so. Otherwise, doctor please complete immediately, inability or failure of a 
patient to complete this portion shall not affect his/her rights to workers' compensation under the California Labor Code. 
17. Describe how the accident or exposure happened. (Give specific object, machinery or chemical. Use reverse side if more space is required.)  

18. SUBJECTIVE COMPLAINTS

 19. Objective Findings 

 A. Physical Examination

 B. X-ray and laboratory results (State if none or pending.) 

Form 5021 (Rev. 5) 10/2015                                 Sheet 1 of 3 

 STATE OF CALIFORNIA 
                              DOCTOR'S FIRST REPORT OF OCCUPATIONAL INJURY OR ILLNESS 

 20. DIAGNOSES(if occupational illness specify etiologic agent and duration of exposure.) Chemical or toxic compounds involved?  

1.                                                                                                          ICD-10 
2.                                                                                                          ICD-10 
3.                                                                                                          ICD-10 
4.                                                                                                          ICD-10 
5.                                                                                                          ICD-10 
6.                                                                                                          ICD-10 
7.                                                                                                          ICD-10 
8.                                                                                                          ICD-10 
9.                                                                                                          ICD-10 
10.                                                                                                         ICD-10 
11.                                                                                                         ICD-10 
12.                                                                                                         ICD-10 

21.Are your findings and diagnosis consistent with patient's account of injury or onset of illness?      If "no," please explain below: 

22.Is there any other current condition that will impede or delay patient's recovery?                    If "yes," please explain below: 

 23. TREATMENT RENDERED (Use reverse side if more space is required.) 

 24. If further treatment required, specify treatment plan/estimated duration. 

 25. If hospitalized as inpatient, give hospital name and location 

                                                                                           Date admitted Estimated length of stay 

26. WORK STATUS - Is patient able to perform usual work?                          Yes               No
 If "no", date when patient can return to                                         Regular work           Modified work 

 Specify restrictions 

Form 5021 (Rev. 5) 10/2015 
                                                                            Sheet 2 of 3 

                                                 STATE OF CALIFORNIA 
                    DOCTOR'S FIRST REPORT OF OCCUPATIONAL INJURY OR ILLNESS 

Physician Signature: (original signature, do not stamp) 
I declare under penalty of perjury that this report is true and correct to the best of my knowledge and that I have not violated 
 Labor Code section 139.3. 

Physician signature                                                  Cal. License Number: 

Executed at:                                                         Date (mm/dd/yyyy): 

Physician Name                                                       Specialty: 

Physician address:                                                   Phone Number 

 Any person who makes or causes to be made any knowingly fraudulent material statement or material representation for the 
               purpose of obtaining or denying workers' compensation benefits or payments is guilty of a felony. 

 PRIVACY NOTICE: The Administrative Director is authorized to maintain the records of the Division of Workers' Compensation (DWC).  (Cal. Lab. Code 
§ 126.) The Information Practices Act of 1977 and the Federal Privacy Act require the Administrative Director to provide this notice to individuals who 
submit information to the DWC pertaining to a workers' compensation claim. (Cal. Civ. Code § 1798.17; Public Law 93-579.)  
The principal purpose for requesting information from injured workers, dependents, lien claimants, physician, employers or their representatives is to 
administer the California workers' compensation system. Each form shows which fields are required to be completed for DWC to process the form.  If a 
required field in a form is incomplete or unreadable, the DWC may return the form to the individual for correction or may reject the form.  Providing a social 
security number is required on this form pursuant to Labor Code § 6409. If you do not provide your security number, the DWC may return the form to you for 
correction or reject the form. If you do not have a social security number, indicate this in the space provided for the injured worker's social security number. 
As permitted by law, social security numbers are used to help properly identify injured workers and to conduct statistical research as allowed under the Labor 
Code. 

As authorized by law, information furnished on this form may be given to: you, upon request; the public, pursuant to the Public Records Act; a governmental 
entity, when required by state or federal law; to any person, pursuant to a subpoena or court order pursuant to any other exception in Civil Code § 1798.24. 

An individual has a right of access to records containing his/her personal information that are maintained by the Administrative Director.  An individual may 
also amend, correct, or dispute information in such personal records. (Cal. Civ. Code §§ 1798.34-1798.3.) You may request a copy of the DWC's policies and 
procedures for inspection of records at the address below. Copies of the procedures and all records are ten cents ($0.10) per page, payable in advance.  (Cal. 
Civ. Code § 1798.33.) Requests should be sent to: Division of Workers' Compensation- Medical Unit, P.O. Box 71010, Oakland, CA 94612.  Tel: (510) 
286-3700 or (800) 794.6900. Fax: (510) 622-3467. 

 Form 5021 (Rev. 5) 10/2015                             Sheet 3 of 3