When workers in Wisconsin experience an accident or develop an industrial disease related to their workplace, navigating the aftermath can be challenging—both for them and the involved entities, such as employers and insurance carriers. The WKC 16 B form, also known as the Practitioner’s Report on Accident or Industrial Disease in Lieu of Testimony, serves as a crucial document within this context. Managed by the Department of Workforce Development Worker’s Compensation Division, this form allows medical practitioners to provide a detailed report covering the employee's condition, the treatment provided, and the prognosis. It requires detailed information about the employee, the employer, the specifics of the incidents, and the nature of the disabilities resulted from said incidents—whether they be physical or mental. The form also delves into questions about any permanent disabilities, the expected capacity for the employee to return to work, and the necessity of further treatment. This form is essential because it can be used as prima facie evidence in worker's compensation claims, streamlining the process and possibly eliminating the need for the doctor to provide oral testimony. The statutes set forth by Wisconsin law underscore the importance of this document in the claims process, making it a pivotal piece of documentation for all parties involved in worker’s compensation cases.
| Question | Answer |
|---|---|
| Form Name | Wkc 16 B Form |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | form wkc 16 b, wkc 16 form, wisconsin workers compensation forms, wkc 16b pdf |
PRACTITIONER’S REPORT ON ACCIDENT OR INDUSTRIAL DISEASE IN LIEU OF TESTIMONY
Department of Workforce Development
Worker’s Compensation Division
201 E. Washington Ave., Rm. C100 P.O. Box 7901
Madison, WI
Telephone: (608)
Fax: (608)
FILED ON BEHALF OF:
EMPLOYEE
EMPLOYER OR INSURANCE CARRIER
Provision of your Social Security Number (SSN) is voluntary. Failure to provide it may result in an information processing delay. Personal information you provide may be used for secondary purposes [Privacy Law, s. 15.04 (1)(m), Wisconsin Statutes].
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WC Claim Number |
Employee Name |
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Employee Social Security Number |
Employee Address |
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Employer Name |
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3. Date of Traumatic Event |
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Employer Address |
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Worker’s Compensation Insurance Carrier |
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4. Describe the accidental event or work exposure to which the patient attributes his/her condition. (A copy of medical history or notes containing this information will suffice if complete.)
5. Give a complete description of physical or mental disability and diagnosis. (A copy of the medical history or notes containing this information will suffice if complete and limited to the work injury.)
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Did you treat the patient? If so, between what dates? |
7. Date of last examination or evaluation |
8. Date disability from work began |
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No |
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Date injured was or will be able to return to a limited type of work: |
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State any temporary limitations. |
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Date injured was or will be able to return to full time work subject only to permanent limitations: |
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State any permanent limitations. |
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In your opinion, is it probable that the event in Item 4 directly caused |
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12. If not directly, is it probable that the event described in Item 4 caused |
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the disability? |
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the disability by precipitation, aggravation and acceleration of a pre- |
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existing progressively deteriorating or degenerative condition beyond |
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No |
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normal progression? |
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No |
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If the patient suffers from a condition caused by an appreciable |
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If yes, give date disability from work began: |
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period of work place exposure (from Item 4), was that exposure |
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either the sole cause of the condition, or at least a material |
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contributory causative factor in the condition’s onset or |
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progression? |
Yes |
No |
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14. Has accident or industrial disease resulted in any permanent disability?
Yes
No
15.Estimate percentage of permanent disability to the member, eye or ear involved, or compare to permanent total disability if injury is to torso or head, caused by the accident or work exposure described in Item 4.
16.What elements constitute permanent disability (such as limitation of motion, deformity, weakness, pain, lack of endurance or components of illness, e.g., isoiconias, photo toxicity, liver disease)? If limitation of motion, describe nature and percentage of limitation of each part of each member affected. (Make estimates on voluntary, not passive motions.) If amputation, state exact point bone was amputated and whether stump is tender or hardy.
17.What is the prognosis of this disability? If guarded, please explain:
18.Do you expect that any further treatment will be necessary for this condition?
Yes
No If YES, explain:
19. Prior to this accident or illness, did employee have any permanent disability?
Yes
No If YES, explain:
20.I am a practitioner licensed in and practicing in Wisconsin. Practitioner Typed or Printed Name:
Practitioner Address (Street or P.O. Box):
Practitioner Address (City, State and Zip Code):
Practitioner Phone Number:
( ) -
College:
CERTIFICATION
I certify, subject to the penalty of fine and/or imprisonment, as provided in Sec. 943.39 of the Wisconsin Statutes, that the above report truly and correctly sets forth the history, my findings, diagnosis and opinion.
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Signature of Practitioner |
Date Signed |
If not licensed and practicing in Wisconsin, state where practitioner is licensed and practicing:
IMPORTANT: Section 102.17(1)(d) of the Wisconsin Statutes provides that the contents of certified medical and surgical reports presented by parties shall constitute prima facie evidence as to the matter contained therein. Reports must be filed with the department and the other parties fifteen days prior to the date of hearing to be acceptable as evidence. If not so filed, it will be necessary to produce the doctor to give oral testimony at the time of hearing.