This Report must be completed, signed and dated by the treating physician only.
Return to work: the date the patient was able to return to work, with restrictions and without restrictions.
Unable to work: if applicable, the dates when the patient was unable to work.
Future treatment: whether you anticipate the need for future medical treatment for this injury.
Impairment rating: use the 6th edition of AMA Guides to determine the impairment rating.
Injuries on or after July 1, 2014: a percentage to the body as a whole.
Injuries prior to July 1, 2014: a percentage to a body part, left or right.
| Question | Answer |
|---|---|
| Form Name | Form C-30A |
| Form Length | 1 page |
| Fillable? | Yes |
| Fillable fields | 33 |
| Avg. time to fill out | 6 min |
| Edition | 1/17 |
| Issuing agency | Tennessee Bureau of Workers' Compensation |
| Who signs | The treating physician |
| Matches the agency's file | Yes, checked October 1, 2026 |
| Other names | C-30A, C30A, C 30A, Form C-30A, Tennessee C-30A, C30, Final Medical Report |
| Official source | Form C-30A (Rev 1/17), Tennessee Bureau of Workers' Compensation |
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