The QME should complete the form in its entirety.
Findings: the QME is required by Labor Code section 4062.3(i) to summarize the medical findings from the medical-legal evaluation on the form.
Event Dates: supplying the Event Dates is a legal requirement.
Signature: under the Labor Code, all QME reports must be signed under the penalty of perjury.
| Question | Answer |
|---|---|
| Form Name | QME Form 111 |
| Form Length | 4 pages |
| Fillable? | Yes |
| Fillable fields | 70 |
| Avg. time to fill out | 12 min |
| Edition | Rev February 2009 |
| Issuing agency | Division of Workers' Compensation - Medical Unit |
| Serving | The QME is required to serve the medical-legal report and this form on the claims administrator, or if none the employer, and the injured worker (except when section 36.5 of Title 8 of the California Code of Regulations applies) within 30 days from the commencement of the examination, unless certain conditions are met |
| Matches the agency's file | Yes, checked October 2, 2026 |
| Other names | QME Form 111, QME 111, Form 111, QME Findings Summary Form, Qualified Medical Evaluator's Findings Summary Form |
| Official source | QME Form 111 (rev. February 2009), Division of Workers' Compensation |
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