How to Fill Out and Submit California Form 5021: Doctor’s First Report

California Form 5021, the Doctor’s First Report of Occupational Injury or Illness, must be completed by the physician who first examines an injured or ill worker and filed with the employer’s workers’ compensation insurer (or the self-insured employer) within five days of that examination.¹ The current version is Rev. 5, required for any date of service on or after October 1, 2015.² The form records the patient’s account of the injury, the physician’s objective findings, diagnoses, treatment, and work restrictions.

Who Files and When

The filing obligation belongs to the physician who first examines the worker. Under Labor Code Section 3209.3, “physician” covers medical doctors, doctors of osteopathy, psychologists, acupuncturists, optometrists, dentists, podiatrists, and chiropractors licensed in California and practicing within their scope.³ If a chiropractor is the first to treat a work-related back injury, the chiropractor files.

There is no severity threshold for the physician’s duty. Labor Code Section 6409 requires a report for every occupational injury or illness a physician treats, regardless of whether the worker lost time beyond the day of injury.¹ The familiar “first aid only” carve-out applies to the employer’s separate reporting duty under Section 6409.1, not to the physician’s. If you provided professional medical treatment, you file.

The patient fills in the section describing how the injury happened. If the patient’s condition prevents them from doing so, the physician fills it in instead, and the form states that this does not affect the worker’s workers’ compensation rights.⁴

Getting the Right Version of the Form

Form 5021 (Rev. 5) is posted as a fillable PDF on the Division of Workers’ Compensation forms page at the Department of Industrial Relations.⁵ The DIR recommends downloading the file to your desktop before completing it.

Insurers, self-insured employers, clinics, and hospitals may reproduce the form on standard 8½-by-11-inch paper, as long as they preserve the required headings, the fraud warning, the filing instructions, and the sequence of Questions 1 through 25.² Many carriers distribute pre-printed versions with their name and claims address already in place.

Completing the Form Section by Section

The form has three working zones: identifying information at the top, clinical findings in the middle, and the signature block at the bottom.⁴

Identifying Information (Items 1–16)

Item 1 asks for the workers’ compensation insurer’s name and address. If the employer is self-insured, enter the employer’s claims administrator.
Items 2 through 4 cover the employer’s legal name, street address, city, zip code, and nature of business.
Items 5 through 11 cover the employee: full name, sex, date of birth, home address, phone, specific job title, and Social Security number. The SSN is required by statute, and leaving it blank is a standalone basis for rejection.
Item 12 is the street address, city, and county where the injury or exposure occurred, which may differ from the employer’s main address.
Items 13 and 14 record the date and hour of the injury or onset of illness and the date the employee last worked.
Items 15 and 16 record the date and hour of your first examination and whether you or your office previously treated this patient.

Clinical Findings (Items 17–25)

Item 17 is the patient’s own description of how the injury happened. Use the patient’s words, not medical terminology.
Item 18 records subjective complaints: pain, limitations, numbness, and other symptoms that can’t be independently measured.
Item 19 has two parts. Part A is your physical examination findings (swelling, range-of-motion deficits, bruising). Part B is X-ray and lab results. If imaging or labs are pending, say so explicitly rather than leaving the field blank.
Item 20 provides up to twelve diagnosis lines with ICD-10 codes. For occupational illnesses, specify the causative agent and the length of exposure, and indicate whether a chemical or toxic compound is involved.
Item 21 asks whether your findings and diagnosis are consistent with the patient’s account. A “no” answer will not end the claim, but it invites closer review from the claims administrator.
Item 22 identifies any other current condition that could slow recovery.
Item 23 lists treatment rendered at this visit: medications, wound care, splinting, referrals.
Item 24 describes the treatment plan and estimated duration if further care is needed.
Item 25 records inpatient admission details: hospital name, location, admission date, and estimated length of stay.

Work Status (Item 26)

Item 26 asks whether the patient can perform their usual job. The options are regular work, modified work with specified restrictions, or unable to work. Section 6409 requires the report to include “any work restrictions resulting from the injury or illness,” so vague answers create problems.¹ Spell out lifting limits, standing restrictions, and repetitive-motion limitations so the employer can decide whether modified duty is possible.

Signature Block

Sign with an original signature. The form specifies “do not stamp.” Include your California license number, specialty, office address, phone number, and the date.

Common Errors That Get the Form Returned

The DWC warns on the form that incomplete or unreadable required fields may result in the form being returned for correction or rejected outright.⁴ The problems that come up most often:

Missing Social Security number. The form flags this specifically.
Blank objective findings. “See chart” or an empty Item 19 forces the claims administrator to request records separately.
Vague work status. “Off work until further notice” gives the employer nothing to act on.
Pending results with no follow-up. Noting that X-rays are pending is fine, but if no supplemental report ever arrives, the file stays incomplete.
Wrong insurer. Carriers change, especially mid-policy-year. Confirm the current carrier with the employer before filing.

Where and How to Submit

File within five days of the initial examination. California Code of Regulations, Title 8, Section 14003 requires the physician to file the original signed report with the employer’s insurer, or directly with the employer if the employer is self-insured.⁶ The form’s own instructions direct you to send two copies to the workers’ compensation carrier or the insured employer.⁴

Section 6409 was amended to require electronic filing with both the Division of Workers’ Compensation and the employer or insurer.¹ The DWC has launched an online electronic reporting system, but according to the DWC’s site it remains a pilot program and physicians are not yet required to participate. The DWC has stated it plans to draft regulations making electronic reporting mandatory and eventually phasing out paper filing.⁷ Until those regulations take effect, paper submission by mail or secure fax remains the standard method.

Extra Steps for Pesticide Poisoning

If the injury involves diagnosed or suspected pesticide poisoning, two additional steps apply. Notify your local health officer by telephone within 24 hours of the initial examination, and send a copy of the report to the Department of Industrial Relations at P.O. Box 420603, San Francisco, CA 94142-0603.⁴

The statute attaches a financial consequence. A physician who treats pesticide poisoning will not be compensated for the initial diagnosis and treatment unless the report is filed with a signed affidavit certifying that a copy went to the local health officer.¹

Penalties for Missing the Deadline

Under Labor Code Section 6413.5, a physician who fails to comply with the reporting requirements of Section 6409 may be assessed a civil penalty of $50 to $200. The penalty applies when the Director of Industrial Relations or their designee finds a pattern or practice of violations, or a willful violation.⁸ A single late report is unlikely to trigger enforcement, but a habit of filing late or not at all invites scrutiny. Beyond the fine, a late Form 5021 slows the claims administrator’s investigation and can hold up the worker’s benefits.

1
California Legislative Information. California Labor Code 6409
2
Department of Industrial Relations. California Code of Regulations, Title 8, Section 14007 – Reproduction of the Doctors Report
3
California Legislative Information. California Labor Code 3209.3
4
Department of Industrial Relations. Doctor’s First Report of Occupational Injury or Illness
5
Department of Industrial Relations. DWC Forms
6
Department of Industrial Relations. California Code of Regulations, Title 8, Section 14003 – Physician
7
Department of Industrial Relations. Electronic Reporting System for Doctors First Report of Injury
8
California Legislative Information. California Labor Code 6413.5