DRAFT FORM on Causation:
This form is to be completed by a physician, and signed by a physician who has evaluated ______for a condition that may be, or may not be work-related.
1. What diagnosis (diagnoses) has/have been made? ______
ICD-9 or ICD-10 code ______
What objective data support this diagnosis (diagnoses)? ______
2. Has a specific injury event occurred that is capable of causing this diagnosis?
On what date was the event? ______
Describe the injury-related event ______
3. For cases with a history of a minor event that does not usually cause injury, is it likely that this condition or these symptoms pre-existed the minor event at work? Yes ____ No ____ If this event does not usually cause injury, is there objective evidence that this person has a disease making him/her susceptible to this diagnosis (e.g. osteoporosis predisposes to fracture)? Yes ____ No ____ List the pre-existing diagnosis ______
Does the onset of symptoms from this pre-existing diagnosis appear to have occurred while this person was at work, but the disease was not caused by this person’s work? (e.g. onset of first episode of angina while climbing stairs at work) Yes ____ No ______
4. For cases with no specific injury event, is there sufficient epidemiologic data to support an association of this diagnosis with this person’s work activity, with a relative risk or hazard ration of > 2.0 in prospective studies? Yes ___ No ____ Don’t know____ If “Yes”, please cite references to the study or studies ______
5. Have you been provided with a job description by the employer, or a video of the job? Yes ____ No ____ If “Yes”, what ergonomic risk or exposure risk do you recognize, and how often and/or how intensely does that exposure occur in this job? ______
6. Are there personal risk factors (e.g., age, handedness, obesity, diabetes, genetics, etc.) that are established risk factors for this diagnosis? If “Yes”, please list the personal risk factors, relative risks or hazard ratios, and references. ______
If you are not aware of established risk factors for this diagnosis, check here _____
7. Does the onset of symptoms from this diagnosis appear to have occurred while this person was at work but the injury or disease was not caused by this person’s work? (e.g. onset of first episode of angina while climbing stairs at work) Yes ____ No ____
8. Considering all of the above evidence, within reasonable medical probability, is it more likely than not that this person’s work activity and appropriate diagnosis, considering all possible causes, contributed more than 50% in causing this person’s death, disablement, or need for treatment? Yes ____ No ____
Check here ___ if you are not comfortable completing this form or believe that someone else should do formal causation analysis in this case
Check here ___ if you are willing to treat this person under either workers’ compensation, or health insurance.
Signed ______MD/DO Date ______