Office of Risk Management and Security Services

Prince William County Public Schools

Office of Risk Management and Security Services

TRANSMITTAL SHEET

THIS FORM IS TO BE PRESENTED TO THE PHYSICIAN FOR EACH VISIT

EMPLOYEE NAME: ______

DATE OF INJURY: ___/______/______SCHOOL/DEPT: ______

JOB TITLE: ______SUPERVISOR: ______

The employee should complete the above information prior to presenting to physician

DIAGNOSIS: ______

IS THERE DISABILITY FROM WORK: NO YES

No Work From: ____/____/____ To: ____/____/____

DATE CAN RETURN TO MODIFIED DUTY: _____/______/______

RESTRICTIONS (Check all that apply)

Sedentary duty? Yes ___ No ___ # of Hours ______

Lifting Restrictions? Yes ___ No ___ (Indicate maximum allowed)____ # of lbs Circle: Freq / Occasionally

Activity / Yes / No / Hrs./Mins / Activity / Yes / No
Sitting / Hrs Mins / Use Left Arm / Hrs Mins
Standing/Walking / Hrs Mins / Use Right Arm / Hrs Mins
Bending/Stooping / Hrs Mins / Driving car/truck / Hrs Mins
Reaching above shoulder / Hrs Mins / Driving School bus / Hrs Mins
Climbing / Hrs Mins / Squatting / Hrs Mins

DATE CAN RETURN TO REGULAR DUTY: ____/______/______

FOLLOW UP REQUIRED: YES NO

DATE FOR RETURN VISIT: ___/___/____

NAME OF MEDICAL FACILITY: (PLEASE PRINT) ______

SIGNATURE OF PHYSICIAN: ______

PRINT NAME OF PHYSICIAN: ______

DATE OF TREATMENT: ___/___/____

The bearer, an employee of Prince William County School Division, is referred to you for treatment of a work related injury/illness. Please forward your itemized bill together with corresponding medical reports to PMA Companies, P.O. Box 5231, Janesville, WI 53547. Cooperation in completing this form will help expedite payment of bills.

Risk Management & Security Services: Shane Peters 703.791.8328 or 703.791.7206 Fax: 703.791.7404

PMA Companies: Tel: 1.888.476.2669

REVISED: 07/07/2016