Free APPENDIX A - Tennessee

FORM C-30 TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT Division of Workers' Compensation 220 French Landing Dr. Nashville, Tennessee 37243-1002

ATTENDING PHYSICIAN'S REPORT
It is a crime to knowingly provide false, incomplete or misleading information to any party to a workers' compensation transaction for the purpose of committing fraud. Penalties include imprisonment, fines and denial of insurance benefits. 1. Name of Injured Person: SSN: Age: 2. Address: City: 3. Employer Name: Address: City: 4. Date of Accident: Hour: AM/PM 5. State in patient's own words where and how accident occurred: Sex: State:

PATIENT

Zip:

ACCIDENT

State: Zip: Date of Disability:

6. Give accurate description of nature and extent of injury and state your objective findings:

TREATMENT DISABILITY

7. Is accident referred to above only cause of patient's condition? If not, state contributing causes: 8. Is patient suffering from any disease of the heart, lungs, brain, kidneys, blood, vascular system or any other disabling condition not due to this accident? Give particulars: 9. Has patient any physical impairment due to previous accident or disease? Give particulars: 10. Has normal recovery been delayed for any reason? Give particulars: 11. Who engaged your services? 12. Date of your first treatment: 13. Describe treatment given by you: 14. Was patient treated by anyone else? When? 15. Was patient hospitalized? Name of hospital: Address of hospital: 16. Date of admission to hospital: Date of discharge: 17. Is further treatment needed? For how long? 18. Will the injury result in: (a) Permanent Defect? If so, what? (b) Facial or head disfigurement? 19. Date able to return to work: 20. Date able to return to work light duty: 21. If death ensued, give date: Remarks: (Give any information of value not listed above) This report must be signed personally by physician. Date of report: Address: Signed Telephone:
RDA 10183

LB-0022 (REV. 12/07)

INJURY