Physician's Report on Eye Injuries
Document Number: WKC-16-A-E
Description: This form is to be filed by the insurer or self-insured employer when temporary disability exceeds 3 weeks or permanent disability results.
Comments: This form is an electronic Microsoft Word template that can be filled out on your computer (if you have Microsoft Word).
Content Contact: Kathy Froehlich
WKC-16-A-E (Electronic Version - Word/56 KB)
WKC-16-A (Print Version - pdf/49 KB)
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