Get Ca Calosha Form 5021 1992-2025

Filling out the CA CALOSHA Form 5021 is a vital step in reporting an occupational injury or illness within the required timeframe. This guide provides a detailed, step-by-step approach to help users complete the form accurately and efficiently online.

Follow the steps to successfully complete the CA CALOSHA Form 5021.

1. Click ‘Get Form’ button to access the CA CALOSHA Form 5021 and open it in the editor.
2. Fill in the insurer's name and address at the top of the form in the designated space.
3. Provide the employer's name and address, ensuring to include city, zip code, and county.
4. Describe the nature of the business by entering relevant information such as food manufacturing or construction.
5. Input the patient's full name and address. Make sure to include the city and zip code.
6. Select the patient's sex by choosing either 'Male' or 'Female'.
7. Enter the patient’s date of birth along with their age.
8. Provide the patient's telephone number for future communications.
9. Fill in the patient’s social security number and occupation/status.
10. Describe the location of the injury, including the address, city, and any hazards involved.
11. Specify the date and hour of the injury or onset of the illness.
12. Indicate the date last worked by the patient or the onset of their illness.
13. Record the date and hour of the first examination or treatment provided to the patient.
14. Instruct the patient to describe how the accident or exposure happened. Use additional space if necessary.
15. Detail the subjective complaints from the patient regarding the injury or illness.
16. Provide objective findings, including any physical examination results and laboratory tests.
17. Input the diagnosis of the condition, indicating if it is an occupational illness and citing any relevant chemical exposures.
18. Affirm whether the findings are consistent with the patient's account; provide explanations as necessary.
19. Discuss any other conditions that may impede the patient's recovery, with explanations if applicable.
20. Highlight the treatment rendered and indicate any further treatment required.
21. If hospitalization occurred, specify the hospital name, location, and dates involved.
22. Clarify the patient’s work status and their ability to perform usual work.
23. Sign off with the doctor's signature and include their license number and contact information.
24. Once all fields are completed, save your changes and proceed to download, print, or share the form as needed.

Complete your CA CALOSHA Form 5021 online today to ensure timely reporting and compliance.