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Employee Report of Wages and Physical Condition

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Employee Report of Wages and Physical Condition

Department of Labor & Industry / Bureau of Workers’ Compensation

Employee Social Security Number or WC ID Number:

Employee

First name

Last name

Date of birth

Address

Address

City/Town State ZIP

County

Telephone

Employer

Name

Address

Address

City/Town State ZIP

County

Telephone FEIN

Insurer or Third Party Administrator

Name

Address

Address

City/Town State ZIP

County

Telephone FEIN

NAIC code or Insurer code

Insurer/TPA claim #

Failure to complete this form may subject you to Article XI of the WC Act relating to fraud.

You must complete and return this form within 30 days of beginning employment or self-employment.

Date of Injury: WCAIS Claim Number:

1. Are you now employed? Yes No

2. Are you now self-employed? Yes No

3. Have you been employed or self-employed at any time while receiving workers’ compensation benefits? Yes No

If you answered yes to one of the questions, please complete the following:

Occupation(s):

4. Has your physical condition (caused by your work injury) changed? Yes No

If yes, attach medical report.

5. Is there any other information you are aware of that is relevant in determining your entitlement to, or amount of compensation?

Yes No

If yes, please explain:

6. Names of employers for whom you have worked since your date of injury:

Name

Address

Address

City/Town State ZIP

Period of employment:

From To

Amount of wages $

Name

Address

Address

City/Town State ZIP

Period of employment:

From To

Amount of wages $

Name

Address

Address

City/Town State ZIP

Period of employment:

From To

Amount of wages $

If Self-Employed

From

To

Amount of wages $

I verify that this information is true and correct based upon my knowledge, information and belief. I understand false statements are subject to the penalties of 18 Pa. C.S. §4904 relating to unsworn falsification to authorities.

Employee

First name

Last name

Signature

Date of Notice

Section 311.1(A) of the Workers’ Compensation Act requires employees who are receiving workers’ compensation, or who have filed a petition to receive workers’ compensation, to report earnings from employment or self-employment. You must complete and return this form to the sender within thirty (30) days of beginning such employment or self-employment.

Employee is to return this completed form to the insurer or third party administrator shown on the front.

Any individual filing misleading or incomplete information knowingly and with the intent to defraud is in violation of Section 1102 of the Pennsylvania Workers’ Compensation Act, 77 P.S. §1039.2, and may also be subject to criminal and civil penalties under 18 Pa. C.S.A. §4117 (relating to insurance fraud).

Employer Information Services

717.772.3702

Claims Information Services

toll-free inside PA: 800.482.2383

local & outside PA: 717.772.4447

Hearing Impaired

toll-free inside PA TTY: 800.362.4228

local & outside PA TTY: 717.772.4991

Email

ra-li-bwc-helpline@pa.gov

Auxiliary aids and services are available upon request to individuals with disabilities.

Equal Opportunity Employer/Program

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What the Employee Report of Wages and Physical Condition Is

The Employee Report of Wages and Physical Condition is a combined personnel record used by employers and occupational health providers to document an employee's earnings and fitness for duty. It records pay periods, taxable and non-taxable earnings, deductions, job title and hours worked alongside results of physical examinations, fitness-for-duty certifications, and any work restrictions. Organizations use it to support payroll processing, workplace safety decisions, return-to-work assessments, and regulatory compliance for labor, workplace safety, and health-related recordkeeping.

Why this report matters to employers and clinicians

A clear combined report centralizes wage details and medical fitness information to streamline payroll, absence management, and accommodation decisions while creating a defensible compliance record under workplace and health regulations.

Why this report matters to employers and clinicians

Who typically completes and relies on this report

Employers, HR professionals, occupational health clinicians, and benefits administrators commonly prepare or review this report when pay status and medical fitness intersect.

  • HR teams managing payroll adjustments, leave, and accommodation eligibility.
  • Occupational health clinicians documenting fitness-for-duty and work restrictions.
  • Workers' compensation and benefits administrators reviewing wage and condition evidence.

Accurate, timely completion reduces disputes, supports lawful accommodation, and preserves audit trails for payroll and health record retention requirements.

Step-by-step: completing the report from top to bottom

Complete the form in the sequence below to ensure payroll and medical sections align and that signatories authenticate in the correct order.

  • 01
    Confirm identity: Verify employee legal name and ID before entering data.
  • 02
    Enter wage data: Record gross pay, deductions, and pay period accurately.
  • 03
    Complete medical section: Document exam date, findings, and any restrictions.
  • 04
    Signatures and dates: Obtain signatures from clinician and authorized employer representative.

Essential components of a professional report

A complete report contains discrete sections that support payroll, health decisions, and recordkeeping while enabling secure transfer and auditability.

Employee details

Name, employee ID, job title, department, worksite address and contact information to uniquely identify the worker.

Wage summary

Gross pay, taxable wages, deductions, pay period dates, hours worked, overtime calculations and year-to-date totals.

Medical exam details

Exam date, clinician name and license number, tests performed, vitals, and objective findings relevant to job tasks.

Fitness conclusion

Clear statement of fit status, functional restrictions, recommended accommodations, and expected duration if temporary.

Authorizations

Employee release, HIPAA-compliant consent where required, and employer authorization for payroll adjustments or restricted duty.

Audit trail

Timestamps, signer identity, and any electronic audit metadata necessary for compliance and dispute resolution.

Required data elements at a glance

Employee ID: Unique identifier
Pay dates: MM/DD/YYYY range
Gross wages: USD two decimals
Exam date: MM/DD/YYYY
Clinician: Name and license
Signature: Signer and date

Common mistakes to avoid

  • Entering pay periods inconsistently, causing payroll reconciliation errors and tax reporting mismatches.
  • Using informal names or nicknames that do not match payroll or identification records.
  • Failing to record the clinician's license or credentials, weakening medical evidence credibility.
  • Omitting fitness restrictions or providing vague recommendations that hinder accommodations.

Potential penalties and legal risks

Tax reporting fines: Incorrect wage reporting may trigger IRC §6721 penalties for information returns.
I-9 and payroll violations: Incomplete employment records can cause DHS or DOL enforcement actions under 8 CFR §274a.2 and 29 CFR §516.5.
HIPAA exposure: Improper handling of health data risks HIPAA liability; BAAs required when applicable (45 CFR §164.502).
ADA disputes: Insufficient fitness details can increase discrimination or failure-to-accommodate claims under ADA.
Evidentiary challenges: Unsigned or poorly authenticated reports may be excluded as evidence in claims or audits.
State penalties: State labor or privacy law violations can add fines beyond federal penalties.

Timing considerations and common deadlines

Track payroll and medical timing to meet tax reporting and internal policy deadlines; different rules apply depending on context.

Payroll reconciliation:

Complete before payroll close for the affected pay period.

Employee notification:

Provide fitness conclusions promptly to support return-to-work decisions.

Tax reporting:

Wage summaries feed year-end forms due per IRS deadlines (e.g., W-2 by Jan 31).

Workers' comp:

Submit required records per state-specific reporting windows for claims.

Record retention:

Retain wage and medical records according to regulatory schedules stated elsewhere in this guide.

Key milestones from examination to retention

Use this milestone sequence to coordinate clinical findings, employer decisions, and recordkeeping obligations.

01

Examination scheduled

Clinician performs exam and documents findings immediately after assessment.

02

Employer review

HR reviews medical findings against job requirements and determines next steps.

03

Accommodation decision

Employer documents any accommodations, restricted duty, or leave arrangements.

04

Finalize payroll

Payroll adjustments processed and wage report updated for affected period.

Where to route completed reports

Route copies to appropriate parties to ensure payroll, health records, and compliance teams have consistent information.

  • Payroll department: Receives wage section for processing and tax reporting reconciliation.
  • Occupational health: Retains medical findings in protected health records per HIPAA.
  • HR and manager: Keeps employment decisions, accommodations, and return-to-work plans.
  • Benefits/claims: Shares necessary data with claims administrators or workers' comp insurers.

Configuring an online completion workflow

Set up fields and routing to mirror paper workflow and to capture required authentication and audit data.

Field Configuration
Wage fields Numeric validation, currency format
Medical fields Restricted access, HIPAA-aware storage
Signer order Clinician first, then employer representative
Audit trail Enable timestamps, IP logging

Technical considerations for digital completion and signing

Choose a platform that supports secure forms, signer authentication, audit trails, and retention controls appropriate for payroll and health data.

  • Document formats: PDF, DOCX supported
  • Authentication: Email, SMS code, or advanced methods
  • Integrations: Payroll and EHR system connectors

Ensure the vendor offers HIPAA protections where required, supports SSO and role-based access, and produces tamper-evident signed documents with comprehensive audit logs.

Comparison of eSignature pricing and basic capabilities for this report

This table compares common starter prices and core capabilities for eSignature vendors used to sign and manage Employee Report of Wages and Physical Condition documents.

signNow DocuSign Adobe Sign PandaDoc HelloSign
Starting Price $8/user/mo $15/user/mo $14/user/mo $19/user/mo $15/user/mo
Free Trial 7-day trial No No No No
Bulk Send Yes Yes Yes Yes No
Audit Trail Yes Yes Yes Yes Yes
HIPAA Compliant Yes Yes Yes No No

Frequently asked questions about the report

Answers to common operational and compliance questions encountered when preparing or processing this combined wage and medical report.


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