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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
(a) Insurers, self-insured employers, doctors, clinics, hospitals and other persons may reproduce Form 5021, Rev. 4 or 5, as appropriate (for dates of service prior to October 1, 2015, use Rev. 4; for dates of service on or after October 1, 2015, use Rev. 5), Doctor's First Report of Occupational Injury or Illness, if all of the following conditions are met:
(1) The title of the reproduced form shall read: Doctor's First Report of Occupational Injury or Illness State of California. The size of type may be reduced to meet space requirements, but the words “Doctor's First Report of Occupational Injury or Illness” shall be in bold face type.
(2) Filing instructions in the heading shall include the requirement for the physician to file a copy of the report directly with the Division of Labor Statistics and Research in the case of pesticide poisoning or suspected pesticide poisoning, and the statement “Failure to file a timely doctor's report may result in assessment of a civil penalty.”
(3) The form shall prominently contain the following statement: “Any person who makes or causes to be made any knowingly false or fraudulent material statement or material representation for the purpose of obtaining or denying workers' compensation benefits or payments is guilty of a felony.”
(4) Reproduced forms shall be printed on 8 1/2″ by 11″ paper stock.
(5) The subheadings, arrangement, sequence and text of Questions 1 through 25, the coding column and the signature section shall not be altered, except that Question 1 may be eliminated on forms printed with the insurer's or self-insured employer's name at the top.
(b) Insurers, self-insured employers, doctors, clinics, hospitals and other persons reproducing Form 5021, may rearrange the heading to permit imprinting:
(1) The name and address of such insurer, self-insured employer, doctor, clinic, hospital or other persons;
(2) Coding lines or boxes for special use by the person reproducing the form;
(3) Instructions for forwarding the form and the number of copies required.
(c) Insurers, self-insured employers and other persons reproducing Form 5021, may use the back of the form for additional information, questions, or skeleton diagrams.
(d) Except as otherwise specified in subdivision 14007(b), any other modification to the content or layout of Form 5021 may be made only with prior approval of a written request to the Department of Industrial Relations, P.O. Box 420603, San Francisco, CA 94142-0603.
Note: Authority cited: Sections 6410 and 6410.5, Labor Code. Reference: Sections 5401.7 and 6410, Labor Code.