Fill and Sign the 1 Introduction This Incident Guide Will Provide an Explanation Form

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 pur pose of committing fraud. Penalties include imprisonment, fines and denial of insurance benefits. 1. Name of Injured Person: SSN: Age: Sex: 2. Address: City: State: Zip: 3. Employer Name: PATIENT Address: City: State: Zip: 4. Date of Accident: Hour: AM/PM Date of Disability: ACCIDENT 5. State in patient’s own words where and how accident occurred: 6. Give accurate description of nature and extent of injury and state your objective findings: 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? INJURY 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: TREATMENT 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: DISABILITY 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: Signed Address: Telephone: LB-0022 ( REV . 12/07) RDA 10183