Tuolumne JPA
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Workers' Compensation Forms

The Workers’ Compensation forms below are for JPA members only.
Select the form you would like to download or print.
d

Designated Hospitals and Clinic Providers

h

DWC 1 Form (fillable pdf)

o

Employee Predesignated Treating Physician Notification

o

Employee - Supervisor Incident Report

i

Form 5020 (fillable pdf)

a

Log for Dispensing Employee DWC1 Claim Form (Excel Spreadsheet)

j

Medical Release

j

Medical Mileage Reimbursement Form (doc)



Notice of Employee Death (fillable pdf)



Notice to Employees-Injuries Caused by Work

Z

Physician Consent to Perform Employment Test

b

Physician Consent to Perform Fit for Duty Test

f

Pre-Employment Physical



Supervisor's Report of Employee Injury (fillable pdf)

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