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RU forms Available for Downloading
Vocational Rehabilitation
Each form may be downloaded in Adobe Acrobat  format. To use the form, first review the
general instructions located here. Then download the form by
clicking on the form number below and follow the specific insturctions
for that form, which is included. Please note that some forms are
used in pairs.
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RU 90 Treating Physician Report
of Disability
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RU 91 Description of Job Duties
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RU 94 Notice of Offer of Modified
or Alternate Work
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RU 102 Rehabilitation Plan
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RU 103 Request for Dispute
Resolution
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RB 105 Request for Conclusion
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RU 105 Notice of Termination
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RB 107 Declination for Date
Of Injury's pre 1/1/90
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RU 107 Declination for Date
Of Injury's 1/1/90 - 12/31/93
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RU 107A Declination for
Date Of Injury's post 1/1/94
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RU 120 Evaluation Summary
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RU 121 Program Report
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RU 122 Settlement of Prospective
Vocational Rehabilitation Services
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(NOTE: Electronic versions of some forms are still being developed.
They will be posted for download as soon as they become available)
WCAB
Disability Evaluation
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DEU 100 Employee's Permanent
Disability Questionnaire
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DEU 101 Request for Summary
Rating Determination (of AME's or QME's Report)
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DEU 102 Request for Summary
Rating Determination (of Primary Treating Physician's Report)
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DEU 103 Request for Reconsideration
of Summary Rating by the Administrataive Director
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DEU 105 Apportionment
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DEU 110 Notice of Options
Following Permanent Disability Rating
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DEU 200 Employee's Request
for Informal Permanent Disability Rating
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DEU 201 Request for Informal
Rating (by Insurance Carrier or Self-Insurer)
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Request for Consultative Rating
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Audit
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Audit Referral Form -
Also available is a one-page guide for completing this form,
developed by the DWC Information and Assistance Unit. The
guide includes the form and is in Adobe Acrobat (.pdf, 20k) format.
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Primary Treating Physician Reports
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PR-2 Primary Treating Physician's
Progress Report(.pdf, 24k) format.
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PR-3 Primary Treating Physician's
Permanent and Stationary Report(.pdf, 32k) format.
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DLSR Form 5021, Doctor's First Report
of Occupational Injury or Illness - Insurers, self-insured
employers, doctors, clinics, hospitals and other persons may
reproduce this form following specifications contained in
Section 14007 of Title 8,
California Code of Regulations. A downloadable copy in Adobe
Acrobat (.pdf, 16k) format can
be found in Section
14006 of the regulations.
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DWC Form 280 Petition
for Change of Primary Treating Physician(.pdf, 60k) format.
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Judicial Ethics
Managed Care
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DWC 1194 HCO Enrollment Form
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HCO Application Instructions (under revision)
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HCO Application (under revision)
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Information and Assistance
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Guides for Injured Workers
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The Injured Worker Pamphlet
in Adobe Acrobat (.pdf, 152k) format
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Trabajadores con Lesiones
Spanish language version of The Injured Worker pamphlet (.pdf, 480k)
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DWC Form 1, Employee's Claim For Workers'
Compensation Benefits - This form is provided to the injured
worker by the employer. Employers obtain it in the quantities
they need from their workers' compensation claims administrator.
A copy is attached to Injured
Worker Guide #1, How to File A Claim Form (.pdf, 137k).
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DLSR Form 5020, Employer's Report of
Occupational Injury or Illness - Employers obtain this
form from their workers' compensation claims administrator.
Insurers and self-insured employers reproduce the form following
all of the conditions contained in Section
14005 of Title 8, California Code of Regulations. A downloadable
copy in Adobe Acrobat (.pdf,
20k) format can be found in Section 14004 of the regulations.
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