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Information & Assistance Unit guide 17How to complete a document cover sheetForms filed with your local Workers’ Compensation Appeals Board (WCAB) officeneed a “document cover sheet.” We need the cover sheet so the information inyour forms can be read by our Electronic Adjudication Management System(EAMS).You may complete the attached document cover sheet using a typewriter or withblock printing. This form can also be completed online /DWCCA 10232 1.pdf.Use the attached sample form as a guide.If you are submitting a form to your local WCAB office for the first time, check theyes box next to the question: “Is this a new case?” If you have previouslysubmitted forms or know you have an open case, check no.If you have more than one case open at your local WCAB office, and the form youare currently filing applies to two or more of these cases, check the box indicating“companion cases exist.”Check the yes box next to “walk-through” if you are hand-delivering yourdocuments to the WCAB office.Fill in the date the form is prepared using the format shown on the sample. Fill inthe case number if you have an open case. If you are submitting this form for twoor more cases, just put one case number in the first section. You will put thecompanion case numbers in the companion case sections.Indicate whether your injury is a “specific injury” or a “cumulative injury.” Aspecific injury is caused by one event, and the specific date of the event should beentered as the start date. Use the date format in the sample form. A cumulativeinjury is caused by repeated events, movements, or exposures at work. Enter botha start date and an end date using the format in the sample form. If you do notknow the start date, use the date one year prior to the end date.Fill in the body part(s) using only the “body part code list” provided on the lastpage. Pick the code(s) which best describes the area of your injury. If you havemore than five injured body parts, contact an Information and Assistance (I&A)officer for further instructions.I&A 17Rev. 06/18
Information & Assistance Unit guide 17Check the correct “unit” box to direct your form to the right unit. Most filings aresent to ADJ.If the form you are filing only applies to one case, you don’t have companioncases, and you only need to fill out the first two sections of the cover sheet. In thissituation, you only print and file the first page of the cover sheet.If the form you are submitting applies to two or more cases, you have companioncases. Fill out a separate section on the cover sheet for each companion case inthe same way you completed the first section. In this situation, print and file allthe pages you fill out.Don’t file blank cover sheet pages.Send the completed filing packet to the correct district office. Office addresses andphone numbers are attached to this guide.Additional instructions for filing forms in EAMS can be found on line in the “EAMSOCR forms handbook” athttp://www.dir.ca.gov/dwc/eams/SampleFiles/EAMS OCR%20handbook.pdf.If you need help, call an Information and Assistance (I&A) office, or attend aworkshop for injured workers. The local I&A phone numbers are attached to thisguide. You can get information on a local workshop from the I&A office or on theWeb at www.dwc.ca.gov.The information contained in this guide is general in nature and is not intended as a substitute forlegal advice. Changes in the law or the specific facts of your case may result in legalinterpretations different than those present here.When sending documents to a district office, please make sure they are not folded or stapled.Send them in a large manila envelope. Please see the EAMS OCR forms handbook for furtherinstructions.I&A 17Rev. 06/18
WORKERS’ COMPENSATION APPEALS BOARD DISTRICT OFFICESANAHEIM, 92806-21311065 North Link, Suite 170Information & Assistance Unit (714) 414-1801SACRAMENTO, 95834-2962160 Promenade Circle, Suite 300Information & Assistance Unit (916) 928-3158BAKERSFIELD, 93301-1929th1800 30 Street, Suite 100Information & Assistance Unit (661) 395-2514SALINAS, 93906-22041880 N Main Street, Suites 100 & 200Information & Assistance (831) 443-3058EUREKA, 95501-0529 * Virtual office *Information & Assistance Unit(707) 441-5723SAN BERNARDINO, 92401-1411464 W Fourth Street, Suite 239Information & Assistance Unit (909) 383-4522FRESNO, 93721-22192550 Mariposa Street, Suite 4078Information & Assistance Unit (559) 445-5355SAN DIEGO, 92108-44247575 Metropolitan Drive, Suite 202Information & Assistance Unit (619) 767-2082LONG BEACH, 90810-18701500 Hughes Way, Suite C203Information & Assistance Unit (424) 450-2565SAN FRANCISCO, 94102-7014nd455 Golden Gate Avenue, 2 FloorInformation & Assistance Unit (415) 703-5020LOS ANGELES, 90013-1105thth320 W 4 Street, 9 FloorInformation & Assistance Unit (213) 576-7389SAN JOSE, 95113-1402100 Paseo de San Antonio, Suite 241Information & Assistance Unit (408) 277-1292MARINA DEL REY, 90292-6902ndrd4720 Lincoln Boulevard, 2 and 3 FloorsInformation & Assistance Unit (310) 482-3820SAN LUIS OBISPO, 93401-87364740 Allene Way, Suite 100Information & Assistance Unit (805) 596-4159OAKLAND, 94612-1499th1515 Clay Street, 6 FloorInformation & Assistance Unit (510) 622-2861SANTA ANA, 92707-77042 MacArthur Place, Suite 600Information & Assistance Unit (714) 942-7576OXNARD, 93030-79121901 N Rice Avenue, Suite 100Information & Assistance Unit (805) 485-3528SANTA BARBARA, 93101-7538 * Satellite office *130 E Ortega StreetInformation & Assistance Unit (805) 568-1390POMONA, 91768-1653732 Corporate Center DriveInformation & Assistance Unit (909) 623-8568SANTA ROSA, 95404-477150 “D” Street, Suite 420Information & Assistance Unit (707) 576-2452REDDING, 96002-0940nd250 Hemsted Drive, 2 Floor, Suite BInformation & Assistance Unit (530) 225-2047STOCKTON, 95202-231431 E Channel Street, Suite 344Information & Assistance Unit (209) 948-7980RIVERSIDE, 92501-33373737 Main Street, Suite 300Information & Assistance Unit (951) 782-4347VAN NUYS, 91401-33706150 Van Nuys Boulevard, Suite 105Information & Assistance Unit (818) 901-5374Rev. 07/21
STATE OF CALIFORNIADWC DISTRICT OFFICESAMPLEDOCUMENT COVERSHEETIs this a new case?YesDMore than 15 Companion CasesDNoCompanion Cases ExistDWalkthroughDTODAY'S DATEDate:(MM/DD/YYYY)EAMS CASE NUMBERCase Number 1SSN:DSpecific InjuryDCumulative InjuryDNoDYOUR SOCIALSECURITY NUMBERDATE OF INJURY(End Date: MM/DD/YYYY)(Start Date: MM/DD/YYYY)(If Specific Injury, use the start date as the specific date of injury)IF NEW CASELEAVE BLANKBody Part 1:USE CODE FROMBODY PART CODE LIST -Body Part 3:SEE PAGE 8Body Part 2:Body Part 4:Other Body Parts:Yes WHEN MORE THAN 5 BODY PARTS USE BODYPART NUMBER 700 IN THIS FIELDPlease check unit to be filed on ( check only one box )DADJCompanion CasesCase Number 2IDDEUDSIFDUEFDSpecific InjuryDCumulative InjuryDDINTSAU(Start Date: MM/DD/YYYY)Body Part 3:Body Part 2:Body Part 4:DWC-CA foITTl 10232.1 Rev. 5/2020 - Page 1 of 8(End Date: MM/DD/YYYY)(If Specific Injury, use the start date as the specific date of injury)Body Part 1:Other Body Parts:0RSU
District office codes for place of venueLegend ta AnaBakersfieldEureka*FresnoLos AngelesLong BeachMarina del linasSanta Barbara**San BernardinoSan DiegoSan FranciscoSan JoseSan Luis ObispoSanta RosaStocktonVan Nuys* Eureka is a satellite office of Santa Rosa district office.** Santa Barbara is a satellite office of Oxnard district office.Use this document to complete forms,but do not file this document with your forms.DWC‐CA form 10232.1 Rev. 5/2020 – Page 7 of 8
BODY PART CODES 0410411420430440450498DescriptionHead - not specifiedBrainEar - not specifiedEar - externalEar - internal including hearingEye - including optic nerves and visionFace - not specifiedJaw - including chin and mandibleMouth - including lips, tongue, throat and tasteTeethNose - including nasal passages, sinus and smellFace - multiple parts any combination of above partsFace - forehead, cheeks, eyelidsScalpSkullHead - multiple injury any combination of above partsNeckUpper extremities - not specifiedArm - above wrist not specifiedArm - upper arm humerusArm - elbow head of radiusArm - forearm radius and ulnaArm - multiple parts any combination of above partsArm - not specifiedWristHand - not wrist or fingersFingersUpper extremities - multiple parts any combination ofabove partsTrunk - not specifiedAbdomen - including internal organs and groinHerniaBack - including back muscles, spine and spinal cordChest - including ribs, breast bone and internal organs ofthe chestHips - including pelvis, pelvic organs, tailbone, coccyx andbuttocksShoulders - scapula and clavicleTrunk - use for side; multiple parts any combination ofabove parts
onLower extremities - not specifiedLegs - above ankles, not specifiedThigh femurKnee PatellaLower leg tibia and fibulaLeg - multiple parts any combination of above partsLeg - not specifiedAnkle malleolusFoot not ankle or toeToesLower extremities - multiple parts any combination of abovepartsMultiple parts more than five major parts use only in fifthposition of listing of body partsBody system - not specificCirculatory system - heart - other than heart attack, blood,arteries, veins, etc.Circulatory system - Heart attackDigestive system - stomachExcretory system - kidneys, bladder, intestines, etc.Musculo-skeletal system - bones, joints, tendons, muscles,etc.Nervous system - not specifiedNervous system - StressNervous system - Psychiatric/psychRespiratory system - lungs, trachea, etc.Skin dermatitis, etc.Reproductive systemsOther body systemsCOVID-19Unclassified - insufficient information to identify body parts
Forms filed with your local Workers' Compensation Appeals Board (WCAB) office need a "document cover sheet." We need the cover sheet so the information in your forms can be read by our Electronic Adjudication Management System (EAMS). You may complete the attached document cover sheet using a typewriter or with block printing.
