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WCB.html

WCB F8/F11 form

HTML icon WCB.html — HTML, 7 kB (8185 bytes)

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<html>
<head>
<title>WCB</title>

<!-- CSS Script that removes textarea and textbox borders when printing ------------------->
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</style>
<style type="text/css">
h1{
	font-size: 14;
	font-weight: bold;
	font-family: Arial;
}
h2{
	font-size: 12;
	font-weight: bold;
	font-family: Arial;
	line-height:20%;
}
table{
	border-width: 1;
	border-color: black;
	border-style: solid;
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p.caption{
	font-size: 10;
	font-family: Arial;
}
.text{
	width: 100%;
	font-family: Arial;
	font-size: 12;
}

</style>
<!-- ----------------------------------------------------------------------------------------- -->

</head>
<body>
<form method="post" action="" name="FormName">

<h1>WCB PHYSICIAN'S REPORT</h1>

<table width="700">
<tr>
	<td>
		<input name="F8" type="checkbox">Physician's First Report (F8)
		<input name="F11" type="checkbox">The worker's condition or treatment has changed (F11)
	</td>
</tr>
</table>

<table width="700">
<tr>
	<td width="50%"><p class="caption">Date of Service<input name="DateOfService" type="text" class="text" oscarDB=today></td>
	<td width="25%"><p class="caption">Date of birth<input name="DOB" type="text" class="text" oscarDB=DOB></td>
	<td width="25%" colspan="2"><p class="caption">WCB Claim Number<input name="WCBClaimNumber" type="text" class="text"></td>
</tr>
<tr>
	<td width="50%"><p class="caption">Employer's name<input name="EmployerName" type="text" class="text"></td>
	<td width="50%" colspan="3"><p class="caption">Worker's Last Name<input name="WorkerLastName" type="text" class="text" oscarDB=patient_nameL></td>
</tr>
<tr> 
	<td width="50%"><p class="caption">Employer's Telephone Number<input name="EmployerPhone" type="text" class="text"></td>
	<td width="30%"><p class="caption"> Worker First Name<input name="WorkerFirstName" type="text" class="text" oscarDB=patient_nameF></td>
	<td width="10%"><p class="caption">Middle Initial<input name="MiddleInitial" type="text" class="text"></td>
	<td width="10%"><p class="caption">Gender<input name="Gender" type="text" class="text" oscarDB=sex></td>
</tr>
<tr>
	<td width="50%"><p class="caption">Operating Location Address<textarea name="EmployerAddress" class="text" style="width:100%; height: 40"></textarea></td>
	<td width="50%" colspan="3"><p class="caption">Mailing Address<textarea name="MailingAddress" class="text" style="width:100%; height: 40" oscarDB=address></textarea></td>
</tr>
<tr>
	<td width="50%"><p class="caption">Date of injury or when patient was first treated for this condition<input name="InjuryDate" type="text" class="text"></td>
	<td width="50%"  colspan="3"><p class="caption">Worker's contact telephone number<input name="WorkerPhone" type="text" class="text" oscarDB=phone></td>
</tr>
<tr>
	<td width="50%"><p class="caption">Who rendered first treatment?<input name="RenderedFirstTreatment" type="text" class="text"></td>
	<td width="50%" colspan="3"><p class="caption">Worker's personal health number from BC Care Card<input name="WorkerPHN" type="text" class="text" oscarDB=HIN></td>
</tr>
<tr>
	<td width="100%" colspan="4"><p class="caption">Are you the worker's regular practitioner?<input name="RegularPractitionerYes" type="checkbox">Yes<input name="RegularPractitionerNo" type="checkbox">No<br>
If YES, how long has the worker been your patient? <input name="0-6" type="Checkbox">0-6 months <input name="7-12" type="checkbox">7-12 months<input name="GreaterThan1Year" type="checkbox">&gt; 1year</td>
</tr>
<tr>
	<td width="100%" colspan="4"><p class="caption">Are there prior or other problems affecting injury, recovery, and disability?<br><textarea name="PriorProblems" class="text" style="width: 100%; height: 20"></textarea>
</tr>
<tr>
	<td width="100%" colspan="4"><p class="caption"> From injury or last report, has the worker been disabled from work?<input name="DisabledYes" type="checkbox">Yes<input name="DisabledNo" type="checkbox">No&nbsp&nbsp&nbsp&nbsp&nbsp If Yes, as of what date?<input name="DisabledDate" type="text" class="class" style="width:25%;"></td>
</tr>
</table>
<h2>Injury Codes and Descriptions</h2>
<table width="700">
<tr>
	<td colspan="3"><p class="caption">Diagnosis (text)<input name="Diagnosis" type="text" class="text"></td>
</tr>
<tr>
	<td><p class="caption"> CSABP/AP (codes)<input name="CSABPcode" type="text" class="text"></td>
	<td><p class="caption"> CSANOI (code) <input name="CSANOIcode" type="text" class="text"></td>
	<td><p class="caption">ICD9 (code)<input name="ICD9code" type="text" class="text"></td>
</tr>
</table>

<h2>Clinical Information</h2>
<table width="700">
<tr>
	<td><p class="caption">What happened? Subjective Sx , examinations, investigations, treatments/meds, specialists consult?<textarea name="ClinicalInfo" class="text" style="width:100%; height:140"></textarea></td>
</tr>
</table>
<h2>Return-to-work Planning</h2>
<table width="700">
<tr>
	<td><p class="caption">Is the worker now medically capable of working full duties, full time? <input name="FullDutiesYes" type="checkbox">YES<input name="FullDutiesNo" type="checkbox">NO<br>If NO, what are the current physical and/or psychological restrictions? <textarea name="Restrictions" class="text" style="width:100%; height: 20"></textarea></td>
</tr>	
<tr>
	<td><p class="caption">Estimated time before the worker will be able to return to the workplace in any capacity<br>
	<input name="CurrentlyAtWork" type="checkbox">Currently at work &nbsp&nbsp&nbsp&nbsp&nbsp&nbsp&nbsp&nbsp&nbsp&nbsp
	<input name="1-6d" type="checkbox">1-6 days &nbsp&nbsp&nbsp&nbsp&nbsp &nbsp&nbsp&nbsp&nbsp&nbsp
	<input name="7-13d" type="checkbox">7-13 days &nbsp&nbsp&nbsp&nbsp&nbsp&nbsp&nbsp&nbsp&nbsp&nbsp
	<input name="14-20d" type="checkbox">14-20 days &nbsp&nbsp&nbsp&nbsp&nbsp&nbsp&nbsp&nbsp&nbsp&nbsp
	<input name="GreaterThan20d" type="checkbox">&gt; 20 days</td>
</tr>
<tr>
	<td>
	<p class="caption">If appropriate, is the worker now ready for a rehabilitation program? 
		<input name="RehabYes" type="checkbox">YES&nbsp&nbsp&nbsp&nbsp&nbsp 
		<input name="RehabNo" type="checkbox">NO &nbsp&nbsp&nbsp&nbsp&nbsp&nbsp&nbsp&nbsp&nbsp&nbsp
	 If YES, select
		 <input name="RehabWCP" type="checkbox">WCP &nbsp&nbsp&nbsp&nbsp&nbsp
		 <input name="RehabOther" type="checkbox">Other</td>
</tr>
<tr>
	<td><p class="caption">Do you wish to consult with a WorkSafeBC physician or nurse advisor?
		<input name="ConsultYes" type="checkbox">YES &nbsp&nbsp&nbsp&nbsp
		<input name="ConsultNo" type="checkbox">NO
	</td>
</tr>
<tr>
	<td><p class="caption">If possible, please estimate date of maximal medical recovery <input name="RecoveryDate" type="text" class="text"></td>
</tr>
</table>

<table width="700">
<tr>
	<td><p class="caption">Payee Number<input name="PayeeNumber" type="text" class="text"></td>
	<td><p class="caption">Practitioner Number<input name="PractitionerNumber" type="text" class="text"></td>
</tr>
<tr>
	<td><p class="caption">Payee Name<input name="PayeeName" type="text" class="text"></td>
	<td><p class="caption">Practitioner Name<input name="PractionerName" type="text" class="text"></td>
</tr>
</table>

<br><br><br>

<div class="DoNotPrint">
<table width="700">
	<tr>
		<td>
			Subject: <input name="subject" size="40" type="text">
			<input value="Submit" name="B1" type="submit">
			<input value="Reset" name="B2" type="reset">
			<input value="Print" onclick="window.print()" type="button">
		</td>
	</tr>
</table>
</div>
</form>

</body>
</html>

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