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Chapter 7. Division of Labor Statistics and Research
Subchapter 1. Occupational Injury or Illness Reports and Records

Article 1. Reporting of Occupational Injury or Illness

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§14003. Physician.

(a) Every physician, as defined in Labor Code Section 3209.3, who attends an injured employee shall file, within five days after initial examination, a complete report of every occupational injury or occupational illness to such employee, with the employer's insurer, or with the employer, if self-insured. The injured or ill employee, if able to do so, shall complete a portion of such report describing how the injury or illness occurred. Unless the report is transmitted on computer input media, the physician shall file the original signed report with the insurer or self-insured employer.

(b) If treatment is for pesticide poisoning or for a condition suspected to be pesticide poisoning, the physician shall also file a complete report directly with the Division within five days after initial treatment. In no case shall treatment administered for pesticide poisoning or suspected pesticide poisoning be deemed to be first aid treatment.

(c) The reports required by this Section shall be made on Form 5021, Rev. 4, Doctor's First Report of Occupational Injury or Illness (sample forms may be secured from the Division), upon a form reproduced in accordance with Section 14007, or by use of computer input media prescribed by the Division and compatible with the Division's computer equipment. However, reports may be submitted on Revision 3 of Form 5021 until June 30, 1993.

(d) Physicians who use computerized data collection and reporting systems shall keep the injured worker's statement with the patient's medical records.

NOTE: Authority cited: Section 6410, Labor Code. Reference: Sections 6409(a), 6409.3, and 6410, Labor Code.


1. New section filed 2-8-80; designated effective 5-1-80 (Register 80, No. 6).

2. Amendment of subsection (c) filed 1-13-83; effective thirtieth day thereafter (Register 83, No. 3).

3. Amendment filed 6-14-89; operative 7-14-89 (Register 89, No. 25).

4. Editorial correction of printing error in subsection (a) (Register 90, No. 6).

5. Amendment of subsections (a) and (c) filed 1-14-93; operative 2-16-93 (Register 93, No. 3).

6. Editional correct of printing error in subsection (c) (Register 93, No. 44).

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