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 filled out on your computer (if you have Microsoft Word).

Content Contact:  Kathy Froehlich

Document Attachments:

WKC-16-A-E (Electronic Version - Word/56 KB)

WKC-16-A (Print Version - pdf/49 KB)

*** If you need to access this form in an alternate format, please send an email to the Content Contact listed above.

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