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WKC-16-A-E, Physician's Report on Eye Injuries

Document Number: WKC-16-A-E

Description: This form is to be filed by the insurer or self-insured employer when temporary disability exceeds 3 weeks or permanent disability results.

Comments: This form is an electronic Microsoft Word template that can be filled out on your computer (if you have Microsoft Word). We are also providing a PDF (WKC-16-A) which you can print and complete by hand.

Content Contact: Lynn Weinberger

Document Attachments:

WKC-16-A-E (Electronic Version - Word/158 KB)

WKC-16-A (Print Version - pdf/203 KB)

Note: If you need this form in an alternate format, please send a message to the Content Contact listed above.

Contact Information

For questions about this form, or if you need this form in an alternate format, please see the Content Contact (listed to the left)

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