Transcription
Reset FormSTATE OF CALIFORNIADWC DISTRICT OFFICEPrint FormDOCUMENT COVER SHEETIs this a new case?YesCompanion Cases ExistNoWalkthroughYesNoMore than 15 Companion CasesSSN:Date:(MM/DD/YYYY)Specific InjuryCase Number 1Cumulative Injury(End Date: MM/DD/YYYY)(Start Date: MM/DD/YYYY)(If Specific Injury, use the start date as the specific date of injury)Body Part 1:Body Part 3:Body Part 2:Body Part 4:Other Body Parts:Please check unit to be filed on ( check only one box )ADJDEUSIFUEFSAUINTRSUCompanion CasesSpecific InjuryCase Number 2Cumulative Injury(Start Date: MM/DD/YYYY)(End Date: MM/DD/YYYY)(If Specific Injury, use the start date as the specific date of injury)Body Part 1:Body Part 3:Body Part 2:Body Part 4:Other Body Parts:DWC-CA form 10232.1 Rev. 5/2020 - Page 1 of 8
Specific InjuryCase Number 3Cumulative Injury(Start Date: MM/DD/YYYY)(End Date: MM/DD/YYYY)(If Specific Injury, use the start date as the specific date of injury)Body Part 1:Body Part 3:Body Part 2:Body Part 4:Other Body Parts:Specific InjuryCase Number 4Cumulative Injury(Start Date: MM/DD/YYYY)(End Date: MM/DD/YYYY)(If Specific Injury, use the start date as the specific date of injury)Body Part 1:Body Part 3:Body Part 2:Body Part 4:Other Body Parts:Specific InjuryCase Number 5Cumulative Injury(Start Date: MM/DD/YYYY)(End Date: MM/DD/YYYY)(If Specific Injury, use the start date as the specific date of injury)Body Part 1:Body Part 3:Body Part 2:Body Part 4:Other Body Parts:DWC-CA form 10232.1 Rev. 5/2020 - Page 2 of 8
Specific InjuryCase Number 6Cumulative Injury(Start Date: MM/DD/YYYY)(End Date: MM/DD/YYYY)(If Specific Injury, use the start date as the specific date of injury)Body Part 1:Body Part 3:Body Part 2:Body Part 4:Other Body Parts:Specific InjuryCase Number 7Cumulative Injury(Start Date: MM/DD/YYYY)(End Date: MM/DD/YYYY)(If Specific Injury, use the start date as the specific date of injury)Body Part 1:Body Part 3:Body Part 2:Body Part 4:Other Body Parts:Specific InjuryCase Number 8Cumulative Injury(Start Date: MM/DD/YYYY)(End Date: MM/DD/YYYY)(If Specific Injury, use the start date as the specific date of injury)Body Part 1:Body Part 3:Body Part 2:Body Part 4:Other Body Parts:DWC-CA form 10232.1 Rev. 5/2020 - Page 3 of 8
Specific InjuryCase Number 9Cumulative Injury(Start Date: MM/DD/YYYY)(End Date: MM/DD/YYYY)(If Specific Injury, use the start date as the specific date of injury)Body Part 1:Body Part 3:Body Part 2:Body Part 4:Other Body Parts:Specific InjuryCase Number 10Cumulative Injury(Start Date: MM/DD/YYYY)(End Date: MM/DD/YYYY)(If Specific Injury, use the start date as the specific date of injury)Body Part 1:Body Part 3:Body Part 2:Body Part 4:Other Body Parts:Specific InjuryCase Number 11Cumulative Injury(Start Date: MM/DD/YYYY)(End Date: MM/DD/YYYY)(If Specific Injury, use the start date as the specific date of injury)Body Part 1:Body Part 3:Body Part 2:Body Part 4:Other Body Parts:DWC-CA form 10232.1 Rev. 5/2020 - Page 4 of 8
Specific InjuryCase Number 12Cumulative Injury(Start Date: MM/DD/YYYY)(End Date: MM/DD/YYYY)(If Specific Injury, use the start date as the specific date of injury)Body Part 1:Body Part 3:Body Part 2:Body Part 4:Other Body Parts:Specific InjuryCase Number 13Cumulative Injury(Start Date: MM/DD/YYYY)(End Date: MM/DD/YYYY)(If Specific Injury, use the start date as the specific date of injury)Body Part 1:Body Part 3:Body Part 2:Body Part 4:Other Body Parts:Specific InjuryCase Number 14Cumulative Injury(Start Date: MM/DD/YYYY)(End Date: MM/DD/YYYY)(If Specific Injury, use the start date as the specific date of injury)Body Part 1:Body Part 3:Body Part 2:Body Part 4:Other Body Parts:DWC-CA form 10232.1 Rev. 5/2020 - Page 5 of 8
Specific InjuryCase Number 15Cumulative Injury(Start Date: MM/DD/YYYY)(End Date: MM/DD/YYYY)(If Specific Injury, use the start date as the specific date of injury)Body Part 1:Body Part 3:Body Part 2:Body Part 4:Other Body Parts:Specific InjuryCase Number 16Cumulative Injury(Start Date: MM/DD/YYYY)(End Date: MM/DD/YYYY)(If Specific Injury, use the start date as the specific date of injury)Body Part 1:Body Part 3:Body Part 2:Body Part 4:Other Body Parts:DWC-CA form 10232.1 Rev. 5/2020 - Page 6 of 8
District office codes for place of venueLegendAbbreviationOfficeAHMAnaheimANASanta AnaBAKBakersfieldEUREureka*FREFresnoLAOLos AngelesLBOLong BeachMDRMarina del ideSACSacramentoSALSalinasSBASanta Barbara**SBRSan BernardinoSDOSan DiegoSFOSan FranciscoSJOSan JoseSLOSROSan Luis ObispoSTKStocktonVNOVan NuysSanta Rosa* Eureka is a satellite office of Santa Rosa district office. ** Santa Barbara is a satellite office of the 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 Code ListThe body part codes listed below are used to complete forms that require the listing ofthe part of the body that is in issue. Please do not file this document with your forms.100110120121Head - not specifiedBrainEar - not specifiedEar - external500510511513Lower extremities - not specifiedLegs - above ankles, not specifiedThigh femurKnee Patella124Ear - internal including hearing515Lower leg tibia and fibula130Eye - including optic nerves and vision518Leg - multiple parts any combination of above parts140Face - not specified519Leg - not specified141Jaw - including chin and mandible520Ankle malleolus144145146Mouth - including lips, tongue, throat and tasteTeethNose - including nasal passages, sinus and smell530540598Foot not ankle or toeToesLower extremities - multiple parts any combination of above parts148Face - multiple parts any combination of above parts700149Face - forehead, cheeks, eyelids800150Scalp801160Skull802Multiple parts more than five major parts use only in fifth positionof listing of body partsBody system - not specificCirculatory system - heart -other than heart attack, blood, arteries,veins, etc.Circulatory system - Heart attack198Head - multiple injury any combination of above parts810Digestive system - stomach200300310NeckUpper extremities - not specifiedArm - above wrist not specified820830840Excretory system - kidneys, bladder, intestines, etcMusculo-skeletal system - bones, joints, tendons, muscles, etc.Nervous system - not specified311313315318319320330340398400410411Arm - 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 of above partsTrunk - not specifiedAbdomen - including internal organs and groinHernia841842850860870880900999Nervous system - stressNervous system - Psychiatric/psychRespiratory system - lungs, trachea, etc.Skin dermatitis, etc.Reproductive systemsOther body systemsCOVID-19Unclassified - insufficient information to identify body parts420Back - including back muscles, spine and spinal cord430Chest - including ribs, breast bone and internal organs of the chest440Hips - including pelvis, pelvic organs, tailbone, coccyx and buttocks450Shoulders - scapula and clavicle498Trunk - use for side; multiple parts any combination of above partsUse this document to complete forms, but do not file this document with your forms.DWC-CA form 10232.1 Rev. 5/2020 - Page 8 of 8
DOCUMENT COVER SHEET Is this a new case? Yes . No . Companion Cases . Exist. Walkthrough. Yes . No More than 15 Companion Cases . SSN: Date:(MM/DD/YYYY) Specific Injury . Cumulative Injury (Start Date: MM/DD/YYYY) (End Date: MM/DD/YYYY) (If Specific Injury, use the start date as the specific date of injury) Case Number 1 Body Part 1: Body Part .
