Document Cover Sheet {DWC-CA 10232.1}

STATE OF CALIFORNIA DWC DISTRICT OFFICEDOCUMENT COVER SHEET Please check unit to be filed on ( check only one box ) Is this a new case?Companion CasesWalkthrough (If Specific Injury, use the start date as the specific date of injury)(If Specific Injury, use the start date as the specific date of injury)DWC-CA form 10232.1 Rev. 11/2017- Page 1 of 8 SSN: (End Date: MM/DD/YYYY) (Start Date: MM/DD/YYYY) Specific Injury Cumulative Injury Case Number 1 More than 15 Companion Cases Companion Cases Exist Yes No Date:(MM/DD/YYYY) Yes No (Start Date: MM/DD/YYYY) (End Date: MM/DD/YYYY) Case Number 2 Specific Injury Cumulative Injury ADJ DEU SIF UEF SAU INT RSU Body Part 1: Body Part 3: Body Part 2: Body Part 4: Body Part 2: Body Part 4: Body Part 3: Body Part 1: Other Body Parts: Other Body Parts:(If Specific Injury, use the start date as the specific date of injury)(If Specific Injury, use the start date as the specific date of injury)(If Specific Injury, use the start date as the specific date of injury)DWC-CA form 10232.1 Rev. 11/2017- Page 2 of 8 (End Date: MM/DD/YYYY) (Start Date: MM/DD/YYYY) Case Number 3 (End Date: MM/DD/YYYY) (Start Date: MM/DD/YYYY) Case Number 4 (End Date: MM/DD/YYYY) (Start Date: MM/DD/YYYY) Case Number 5 Specific Injury Cumulative Injury Specific Injury Cumulative Injury Specific Injury Cumulative Injury Body Part 3: Body Part 4: Body Part 2: Body Part 1: Body Part 3: Body Part 4: Body Part 2: Body Part 1: Body Part 3: Body Part 4: Body Part 2: Body Part 1: Other Body Parts: Other Body Parts: Other Body Parts:(If Specific Injury, use the start date as the specific date of injury)(If Specific Injury, use the start date as the specific date of injury)(If Specific Injury, use the start date as the specific date of injury)DWC-CA form 10232.1 Rev. 11/2017- Page 3 of 8 (End Date: MM/DD/YYYY) (Start Date: MM/DD/YYYY) Case Number 6 (End Date: MM/DD/YYYY) (Start Date: MM/DD/YYYY) Case Number 7 (End Date: MM/DD/YYYY) (Start Date: MM/DD/YYYY) Case Number 8 Specific Injury Cumulative Injury Specific Injury Cumulative Injury Specific Injury Cumulative Injury Body Part 3: Body Part 4: Body Part 2: Body Part 1: Body Part 3: Body Part 4: Body Part 2: Body Part 1: Body Part 3: Body Part 4: Body Part 2: Body Part 1: Other Body Parts: Other Body Parts: Other Body Parts:(If Specific Injury, use the start date as the specific date of injury)(If Specific Injury, use the start date as the specific date of injury)(If Specific Injury, use the start date as the specific date of injury)DWC-CA form 10232.1 Rev. 11/2017- Page 4 of 8 (End Date: MM/DD/YYYY) (Start Date: MM/DD/YYYY) Case Number 9 (End Date: MM/DD/YYYY) (Start Date: MM/DD/YYYY) Case Number 10 (End Date: MM/DD/YYYY) (Start Date: MM/DD/YYYY) Case Number 11 Specific Injury Cumulative Injury Specific Injury Cumulative Injury Specific Injury Cumulative Injury Body Part 3: Body Part 4: Body Part 2: Body Part 1: Body Part 3: Body Part 4: Body Part 2: Body Part 1: Body Part 3: Body Part 4: Body Part 2: Body Part 1: Other Body Parts: Other Body Parts: Other Body Parts:(If Specific Injury, use the start date as the specific date of injury)(If Specific Injury, use the start date as the specific date of injury)(If Specific Injury, use the start date as the specific date of injury)DWC-CA form 10232.1 Rev. 11/2017- Page 5 of 8 (End Date: MM/DD/YYYY) (Start Date: MM/DD/YYYY) Case Number 12 (End Date: MM/DD/YYYY) (Start Date: MM/DD/YYYY) Case Number 13 (End Date: MM/DD/YYYY) (Start Date: MM/DD/YYYY) Case Number 14 Specific Injury Cumulative Injury Specific Injury Cumulative Injury Specific Injury Cumulative Injury Body Part 3: Body Part 4: Body Part 2: Body Part 1: Body Part 3: Body Part 4: Body Part 2: Body Part 1: Body Part 3: Body Part 4: Body Part 2: Body Part 1: Other Body Parts: Other Body Parts: Other Body Parts:(If Specific Injury, use the start date as the specific date of injury)(If Specific Injury, use the start date as the specific date of injury)DWC-CA form 10232.1 Rev. 11/2017- Page 6 of 8 (End Date: MM/DD/YYYY) (Start Date: MM/DD/YYYY) Case Number 15 (End Date: MM/DD/YYYY) (Start Date: MM/DD/YYYY) Case Number 16 Specific Injury Cumulative Injury Specific Injury Cumulative Injury Body Part 3: Body Part 4: Body Part 2: Body Part 1: Body Part 3: Body Part 4: Body Part 2: Body Part 1: Other Body Parts: Other Body Parts:District office codes for place of venue DWC-CA form 10232.1 Rev. 11/2017- Page 7 of 8Legend Abbreviation Office AHM Anaheim ANA Santa Ana BAK Bakersfield EUR Eureka* FRE Fresno LAO Los AngelesLBO Long Beach MDR Marina del Rey OAK Oakland OXN Oxnard POM Pomona RDG Redding RIV Riverside SAC Sacramento SAL Salinas SBASanta Barbara**SBR San Bernardino SDO San Diego SFO San Francisco SJO San Jose SLOSan Luis ObispoSRO Santa Rosa STKStockton VNO Van Nuys Use this document to complete forms, but do not file this document with your forms. * Eureka is a satellite office of Santa Rosa district office. ** Santa Barbara is a satellite office of the Oxnard district office.Body Part Code ListThe body part codes listed below are used to complete forms that require the listing of the part of the body that is in issue. Please do not file this document with your forms.Use this document to complete forms, but do not file this document with your forms. DWC-CA form 10232.1 Rev. 11/2017- Page 8 of 8100Head - not specified500Lower extremities - not specified110Brain510Legs - above ankles, not specified120Ear - not specified511Thigh femur121Ear - external513Knee 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 malleolus144Mouth - including lips, tongue, throat and taste530Foot not ankle or toe145Teeth540Toes146Nose - including nasal passages, sinus and smell598Lower extremities - multiple parts any combination of above parts148Face - multiple parts any combination of above parts700Multiple parts more than five major parts use only in fifth position of listing of body parts149Face - forehead, cheeks, eyelids800Body system - not specific150Scalp801Circulatory system - heart -other than heart attack, blood, arteries,veins, etc.160Skull802Circulatory system - Heart attack198Head - multiple injury any combination of above parts810Digestive system - stomach200Neck820Excretory system - kidneys, bladder, intestines, etc300Upper extremities - not specified830Musculo-skeletal system - bones, joints, tendons, muscles, etc.310Arm - above wrist not specified840Nervous system - not specified311Arm - upper arm humerus841Nervous system - stress313Arm - elbow head of radius842Nervous system - Psychiatric/psych315Arm -forearm radius and ulna850Respiratory system - lungs, trachea, etc.318Arm - multiple parts any combination of above parts860Skin dermatitis, etc.319Arm - not specified870Reproductive systems320Wrist880Other body systems330Hand - not wrist or fingers999Unclassified - insufficient information to identify body parts340Fingers398Upper extremities - multiple parts any combination of above parts400Trunk - not specified410Abdomen - including internal organs and groin411Hernia420Back - 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 parts