Wkc 16 B Form PDF Details

This week's blog is all about Work Control 16 B form. This form is used to document or record the work that an individual is doing, as well as their hours worked. The Wkc 16 B form also allows for the tracking of overtime hours worked and any deductions taken from an employee's paychecks. In this blog post, we'll go over how to fill out the Wkc 16 B form accurately and what information you will need to have on hand in order to complete it correctly. Stay tuned!

QuestionAnswer
Form NameWkc 16 B Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesform wkc 16 b, wkc 16 form, wisconsin workers compensation forms, wkc 16b pdf

Form Preview Example

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 53707-7901

Telephone: (608) 266-1340

Fax: (608) 267-0394 http://dwd.wisconsin.gov/wc

e-mail: DWDDWC@dwd.wisconsin.gov

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].

1.

WC Claim Number

Employee Name

 

 

 

 

 

Employee Social Security Number

Employee Address

 

 

 

 

2.

Employer Name

 

3. Date of Traumatic Event

 

 

 

 

 

Employer Address

 

Worker’s Compensation Insurance Carrier

 

 

 

 

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.)

6.

Did you treat the patient? If so, between what dates?

7. Date of last examination or evaluation

8. Date disability from work began

 

Yes

No

and

 

 

 

 

 

 

 

 

 

 

9.

Date injured was or will be able to return to a limited type of work:

 

 

 

 

 

State any temporary limitations.

 

 

 

 

 

 

 

 

10.

Date injured was or will be able to return to full time work subject only to permanent limitations:

 

State any permanent limitations.

 

 

 

 

 

 

 

 

 

11.

In your opinion, is it probable that the event in Item 4 directly caused

 

12. If not directly, is it probable that the event described in Item 4 caused

 

the disability?

 

 

 

the disability by precipitation, aggravation and acceleration of a pre-

 

 

 

 

 

existing progressively deteriorating or degenerative condition beyond

 

Yes

No

 

 

normal progression?

 

 

 

 

 

Yes

No

 

 

 

 

13.

If the patient suffers from a condition caused by an appreciable

 

If yes, give date disability from work began:

 

period of work place exposure (from Item 4), was that exposure

 

 

 

 

 

either the sole cause of the condition, or at least a material

 

 

 

 

 

contributory causative factor in the condition’s onset or

 

 

 

 

 

progression?

Yes

No

 

 

 

 

WKC-16-B (R. 02/2014)

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.

_________________________________________________

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.