The right occupational health form, verified against the source
Workers’ comp, DOT, USCG, OSHA, and drug-testing forms — mirrored from the issuing agency, with the providers who complete them.
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The library serves four workflows. Pick the closest match to skip the noise.
Provider verifying a service
See the form before you commit
Look up the exact federal or state form a service requires so you can confirm scope, signing authority, and submission steps before accepting a referral.
Browse by topicEmployer or HR team
Know what your providers will file
Every form tells you who fills it out, where it goes, electronic-submission status, and how it ties back to a state or federal regulation.
Browse by stateClinician filling out a form
Cite the rule, not the rumor
Each entry links the underlying statute or regulation, calls out NP/PA signing limits, and shows the last verification date.
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Show up prepared
Bilingual EN/ES prep guides cover what to bring, fasting, hydration, and what the visit looks like — so the form gets signed on the first try.
Browse prep guidesBrowse by topic
Jump straight to the regulatory area you’re working in.
Browse by state
State-prescribed workers’ compensation forms, verified against the issuing agency.
All forms
Search by form code, agency, state, or audience. Every entry links back to the official source.
- USCG Mariner Verified
Merchant Mariner Medical Waiver Request
Federal • U.S. Coast Guard – National Maritime Center
There is no numbered waiver form — a medical waiver request is a documentation package submitted with the CG-719K when a mariner does not meet the vision, hearing, or general physical standards. Under 46 CFR 10.303, the Coast Guard may grant a waiver when objective medical evidence shows the condition is sufficiently controlled, and may attach conditions such as more frequent monitoring or operational limitations on the medical certificate.
Verified 2026-07-07 - USCG Mariner Verified
STCW Record of Assessment Forms
Federal • U.S. Coast Guard – National Maritime Center
The NMC publishes per-endorsement Record of Assessment sheets documenting hands-on demonstrations of competence for STCW endorsements (such as OICNW, OICEW, Able Seafarer-Deck, and RFPNW). Each assessment is signed by a Coast Guard-approved Qualified Assessor or Designated Examiner and submitted with the endorsement application under 46 CFR 11.301(a).
Verified 2026-07-07 - USCG Mariner Verified
Merchant Mariner Credential (MMC) Application Packet
Federal • U.S. Coast Guard – National Maritime Center
The MMC application packet is the complete submission the National Maritime Center evaluates: the CG-719B application plus the medical evaluation (CG-719K or CG-719K/E), drug-test documentation (CG-719P or random-program letter), sea service evidence (service letters, discharges, or CG-719S), TWIC proof, training certificates, and fees. The NMC publishes per-endorsement checklists covering age, drug testing, examination, fees, sea service, and TWIC requirements.
Verified 2026-07-07 - USCG Mariner Verified
CG-719S — Small Vessel Sea Service Form
Federal • U.S. Coast Guard – National Maritime Center
CG-719S documents sea service on small vessels toward Merchant Mariner Credential eligibility — vessel name and number, gross tonnage, propulsion, waters navigated, dates, and the capacity served. Under 46 CFR 10.232(a)(4), owners of vessels under 200 GRT may attest to their own service with proof of ownership.
Verified 2026-07-07 - USCG Mariner Verified
CG-719K/E — Application for Medical Certificate — Entry-Level Ratings
Federal • U.S. Coast Guard – National Maritime Center
CG-719K/E is the abbreviated medical evaluation report for mariners applying only for entry-level ratings (such as ordinary seaman, wiper, or steward’s department). It is shorter than the full CG-719K; any application including an officer or STCW endorsement requires the full CG-719K instead.
Verified 2026-07-07 - USCG Mariner Verified
CG-719B — Application for Merchant Mariner Credential (MMC)
Federal • U.S. Coast Guard – National Maritime Center
CG-719B is the base application every mariner files with the National Maritime Center for a Merchant Mariner Credential — original issuance, renewal, raise of grade, new endorsement, or duplicate — and for a Medical Certificate when applying concurrently. The rest of the application packet (medical, drug test, sea service) attaches to this form.
Verified 2026-07-07 - OSHA & Safety Verified
OSHA 301 — Injury and Illness Incident Report
Federal • Occupational Safety and Health Administration (OSHA)
OSHA Form 301 captures the full incident-level details for each recordable case logged on Form 300, including the description of how the injury or illness occurred.
Verified 2026-07-06 - OSHA & Safety Verified
OSHA 300A — Summary of Work-Related Injuries and Illnesses
Federal • Occupational Safety and Health Administration (OSHA)
OSHA Form 300A is the annual summary of recordable injuries and illnesses that covered employers must post and submit electronically under 29 CFR 1904.
Verified 2026-07-06 - OSHA & Safety Verified
OSHA 300 — Log of Work-Related Injuries and Illnesses
Federal • Occupational Safety and Health Administration (OSHA)
OSHA Form 300 is the running log of recordable work-related injuries and illnesses that establishments with more than 10 employees (outside partially exempt industries) must maintain under 29 CFR 1904.
Verified 2026-07-06 - Immigration & USCIS Verified
N-648 — Medical Certification for Disability Exceptions
Federal • U.S. Citizenship and Immigration Services (USCIS)
Form N-648 is used to request an exception to the English and/or civics testing requirements for naturalization when an applicant has a physical or developmental disability or mental impairment that prevents them from meeting those requirements. It is completed by a licensed medical professional.
Verified 2026-05-31 - Immigration & USCIS Verified
I-693 — Report of Immigration Medical Examination and Vaccination Record
Federal • U.S. Citizenship and Immigration Services (USCIS)
Form I-693 documents the results of the immigration medical examination used to establish that an applicant for adjustment of status (or certain other immigration benefits) is not inadmissible on health-related grounds. It must be completed and signed by a USCIS-designated civil surgeon.
Verified 2026-05-31 - DOT / FMCSA Verified
MCSA-5876 — Medical Examiner’s Certificate (DOT)
Federal • Federal Motor Carrier Safety Administration (FMCSA)
MCSA-5876 is the wallet-style Medical Examiner’s Certificate issued to a qualified commercial driver after a passing MCSA-5875 examination. Drivers must carry the certificate; CDL holders self-certify to their state licensing agency.
Verified 2026-05-12 - DOT / FMCSA Verified
MCSA-5875 — Medical Examination Report Form (DOT)
Federal • Federal Motor Carrier Safety Administration (FMCSA)
MCSA-5875 is the DOT Medical Examination Report (MER) form completed by a Certified Medical Examiner during a commercial driver physical. It documents driver health history, examination findings, and certification decision under 49 CFR 391.43.
Verified 2026-05-12 - Drug Testing Verified
CG-719P — Periodic Drug Testing Form
Federal • U.S. Coast Guard – National Maritime Center
CG-719P documents a negative chemical test for dangerous drugs as required for original issuance and renewal of mariner credentials.
Verified 2026-05-12 - USCG Mariner Verified
CG-719K — Application for Merchant Mariner Medical Certificate
Federal • U.S. Coast Guard – National Maritime Center
CG-719K is the medical evaluation form a licensed practitioner completes for any mariner applying for or renewing a Merchant Mariner Credential (MMC) or Medical Certificate. The National Maritime Center reviews submissions and issues the certificate.
Verified 2026-05-12 - Workers’ CompUnverified
WKC-16-B — Practitioner's Report (WKC-16-B)
WI • Wisconsin Department of Workforce Development – Worker’s Compensation Division
Practitioner's Report (WKC-16-B) (WKC-16-B) — state-prescribed clinician report used by the state workers’ comp agency.
Verified 2026-03-27 - Workers’ CompUnverified
APF — Activity Prescription Form
WA • Washington State Department of Labor & Industries (L&I)
Activity Prescription Form (APF) — equivalent or narrative-based clinician report used by the state workers’ comp agency.
Verified 2026-03-27 - Workers’ Comp Verified
DWC Form-073 — Work Status Report
TX • Texas Division of Workers' Compensation (DWC)
Work Status Report (DWC Form-073) — state-prescribed clinician report used by the state workers’ comp agency.
Verified 2026-03-27 - Workers’ CompUnverified
C-42 — Employee's Choice of Physician / Medical Panel
TN • Tennessee Bureau of Workers' Compensation
Employee's Choice of Physician / Medical Panel (C-42) — equivalent or narrative-based clinician report used by the state workers’ comp agency.
Verified 2026-03-27 - Workers’ CompUnverified
Form 827 — Worker's and Health Care Provider's Report (Physician's Part)
OR • Oregon Workers' Compensation Division (WCD)
Worker's and Health Care Provider's Report (Physician's Part) (Form 827) — state-prescribed clinician report used by the state workers’ comp agency.
Verified 2026-03-27 - Workers’ CompUnverified
Form 25R — Rating at End of Healing Period
NC • North Carolina Industrial Commission
Rating at End of Healing Period (Form 25R) — state-prescribed clinician report used by the state workers’ comp agency.
Verified 2026-03-27 - Workers’ Comp Verified
C-4.3 — Doctor's Report of MMI / Permanent Impairment
NY • New York Workers' Compensation Board (WCB)
Doctor's Report of MMI / Permanent Impairment (C-4.3) — state-prescribed clinician report used by the state workers’ comp agency.
Verified 2026-03-27 - Workers’ Comp Verified
C-4.2 — Doctor's Progress Report
NY • New York Workers' Compensation Board (WCB)
Doctor's Progress Report (C-4.2) — state-prescribed clinician report used by the state workers’ comp agency.
Verified 2026-03-27 - Workers’ Comp Verified
C-4 — Doctor's Initial Report of Injury
NY • New York Workers' Compensation Board (WCB)
Doctor's Initial Report of Injury (C-4) — state-prescribed clinician report used by the state workers’ comp agency.
Verified 2026-03-27 - Workers’ CompUnverified
PROPA — Provider's Report of Physical Ability
NM • New Mexico Workers' Compensation Administration (WCA)
Provider's Report of Physical Ability (PROPA) — equivalent or narrative-based clinician report used by the state workers’ comp agency.
Verified 2026-03-27 - Workers’ CompUnverified
Form 1010 — Medical Authorization / Treatment Request
LA • Louisiana Office of Workers' Compensation (OWC)
Medical Authorization / Treatment Request (Form 1010) — state-prescribed clinician report used by the state workers’ comp agency.
Verified 2026-03-27 - Workers’ CompUnverified
WC-2 — Physician's Report
HI • Hawaii Disability Compensation Division (DCD)
Physician's Report (WC-2) — state-prescribed clinician report used by the state workers’ comp agency.
Verified 2026-03-27 - Workers’ CompUnverified
Form 30C Attachment — Medical Report Form / Physician's Report
CT • Connecticut Workers' Compensation Commission
Medical Report Form / Physician's Report (Form 30C Attachment) — state-prescribed clinician report used by the state workers’ comp agency.
Verified 2026-03-27 - Workers’ Comp Verified
PR-2 — Primary Treating Physician's Progress Report
CA • California Division of Workers' Compensation (DWC)
Primary Treating Physician's Progress Report (PR-2) — state-prescribed clinician report used by the state workers’ comp agency.
Verified 2026-03-27 - Workers’ Comp Verified
DWC Form 5021 — Doctor's First Report of Occupational Injury or Illness
CA • California Division of Workers' Compensation (DWC)
Doctor's First Report of Occupational Injury or Illness (DWC Form 5021) — state-prescribed clinician report used by the state workers’ comp agency.
Verified 2026-03-27 - Workers’ CompUnverified
Form 3 — Physician's Report
AR • Arkansas Workers' Compensation Commission
Physician's Report (Form 3) — state-prescribed clinician report used by the state workers’ comp agency.
Verified 2026-03-27 - Workers’ Comp Verified
ICA Form 102 — Worker's and Physician's Report of Injury
AZ • Industrial Commission of Arizona (ICA)
Worker's and Physician's Report of Injury (ICA Form 102) — state-prescribed clinician report used by the state workers’ comp agency.
Verified 2026-03-27 - Workers’ Comp Verified
LIBC-9 — Workers' Compensation Medical Report Form
PA • Pennsylvania Bureau of Workers' Compensation
Workers' Compensation Medical Report Form (LIBC-9) — state-prescribed clinician report used by the state workers’ comp agency.
Verified 2026-03-26 - Workers’ Comp Verified
MEDCO-14 (BWC-3914) — Physician's Report of Work Ability
OH • Ohio Bureau of Workers' Compensation (BWC)
Physician's Report of Work Ability (MEDCO-14 (BWC-3914)) — equivalent or narrative-based clinician report used by the state workers’ comp agency.
Verified 2026-03-26 - Workers’ Comp Verified
C-4 — Employee's Claim / Report of Initial Treatment
NV • Nevada DIR – Workers' Compensation Section
Employee's Claim / Report of Initial Treatment (C-4) — state-prescribed clinician report used by the state workers’ comp agency.
Verified 2026-03-26 - Workers’ Comp Verified
D-39 — Physician/Chiropractic Physician Progress Report – Certification of Disability
NV • Nevada DIR – Workers' Compensation Section
Physician/Chiropractic Physician Progress Report – Certification of Disability (D-39) — state-prescribed clinician report used by the state workers’ comp agency.
Verified 2026-03-26 - Workers’ Comp Verified
CMS-1500 — Treating Physician Report (via CMS-1500)
NE • Nebraska Workers' Compensation Court
Treating Physician Report (via CMS-1500) (CMS-1500) — state-prescribed clinician report used by the state workers’ comp agency.
Verified 2026-03-26 - Workers’ Comp Verified
Medical Status Form
MT • Montana Department of Labor & Industry – Employment Relations Division
Medical Status Form — state-prescribed clinician report used by the state workers’ comp agency.
Verified 2026-03-26 - Workers’ Comp Verified
WC-241 — Eye Injuries with Permanent Disability
MO • Missouri Division of Workers' Compensation
Eye Injuries with Permanent Disability (WC-241) — state-prescribed clinician report used by the state workers’ comp agency.
Verified 2026-03-26 - Workers’ Comp Verified
WC-9 — Medical Treatment Form
MO • Missouri Division of Workers' Compensation
Medical Treatment Form (WC-9) — state-prescribed clinician report used by the state workers’ comp agency.
Verified 2026-03-26 - Workers’ Comp Verified
MWCC Medical Report
MS • Mississippi Workers' Compensation Commission (MWCC)
MWCC Medical Report — state-prescribed clinician report used by the state workers’ comp agency.
Verified 2026-03-26 - Workers’ Comp Verified
RW01 — Report of Work Ability
MN • Minnesota Department of Labor and Industry – Workers' Compensation Division
Report of Work Ability (RW01) — state-prescribed clinician report used by the state workers’ comp agency.
Verified 2026-03-26 - Workers’ Comp Verified
M-1 — Diagnostic Medical Report
ME • Maine Workers' Compensation Board
Diagnostic Medical Report (M-1) — state-prescribed clinician report used by the state workers’ comp agency.
Verified 2026-03-26 - Workers’ Comp Verified
State Form 2118 — Physician's Report
IN • Indiana Workers' Compensation Board
Physician's Report (State Form 2118) — state-prescribed clinician report used by the state workers’ comp agency.
Verified 2026-03-26 - Workers’ Comp Verified
WC-20a — Medical Report
GA • Georgia State Board of Workers' Compensation
Medical Report (WC-20a) — state-prescribed clinician report used by the state workers’ comp agency.
Verified 2026-03-26 - Workers’ Comp Verified
DFS-F5-DWC-25 — Uniform Medical Treatment/Status Report
FL • Florida Division of Workers' Compensation
Uniform Medical Treatment/Status Report (DFS-F5-DWC-25) — state-prescribed clinician report used by the state workers’ comp agency.
Verified 2026-03-26 - Workers’ Comp Verified
WC 164 — Physician's Report of Workers' Compensation Injury
CO • Colorado Division of Workers' Compensation
Physician's Report of Workers' Compensation Injury (WC 164) — state-prescribed clinician report used by the state workers’ comp agency.
Verified 2026-03-26 - Workers’ Comp Verified
Physician's Report
AK • Alaska Department of Labor & Workforce Development – Workers' Compensation Division
Physician's Report — state-prescribed clinician report used by the state workers’ comp agency.
Verified 2026-03-26
Most-requested forms
The handful of forms that come up most often in provider verification calls and HR audits.
- USCG Mariner
CG-719K
Application for Merchant Mariner Medical Certificate
U.S. Coast Guard – National Maritime Center
CG-719K is the medical evaluation form a licensed practitioner completes for any mariner applying for or renewing a Merchant Mariner Credential (MMC) or Medical Certificate. The National Maritime Center reviews submissions and issues the certificate.
Agency source Verified - DOT / FMCSA
MCSA-5875
Medical Examination Report Form (DOT)
Federal Motor Carrier Safety Administration (FMCSA)
MCSA-5875 is the DOT Medical Examination Report (MER) form completed by a Certified Medical Examiner during a commercial driver physical. It documents driver health history, examination findings, and certification decision under 49 CFR 391.43.
Agency source Verified - OSHA & Safety
OSHA 300
Log of Work-Related Injuries and Illnesses
Occupational Safety and Health Administration (OSHA)
OSHA Form 300 is the running log of recordable work-related injuries and illnesses that establishments with more than 10 employees (outside partially exempt industries) must maintain under 29 CFR 1904.
Agency source Verified
Forms come up in these services
If you’re verifying whether a provider can perform a service, start with the service page — it lists the exact forms involved.
- 8 forms
Mariner physical (USCG)
USCG CG-719K medical evaluation and CG-719P drug test for Merchant Mariner Credential issuance and renewal.
See the forms Share employee prep guide - 2 forms
DOT / CDL physical
FMCSA MCSA-5875 examination and MCSA-5876 medical examiner’s certificate for commercial drivers.
See the forms Share employee prep guide - 35 forms
Fitness-for-duty evaluation
Workers’ comp first-report and work-status forms across 28 states, plus return-to-work documentation.
See the forms Share employee prep guide - 33 forms
Return-to-work evaluation
State-prescribed progress and MMI reports that providers complete to release injured workers.
See the forms Share employee prep guide - 1 form
DOT drug testing
Federal CCF chain-of-custody and MRO documentation tied to DOT and USCG drug testing programs.
See the forms Share employee prep guide - 3 forms
Respirator fit testing
OSHA-required medical clearance and recordkeeping for respirator users (29 CFR 1910.134).
See the forms Share employee prep guide
Recent regulatory updates
Forms shift when the rules do. The latest verified changes BlueHive is tracking across state and federal sources.
Jun 26, 2026
OSHA Proposes $3.5M in Penalties Against 3 Employers for Houston Chemical Spill Response Violations
OSHA proposed $3,520,703 in combined penalties against BWC Terminals LLC, Coastal Environmental Solutions Inc., and subcontractor One Way Environmental Services LLC after a December 2025 sulfuric acid
Read post
Jun 23, 2026
FMCSA Revokes TRUCKSTAFF ELD — Carriers Must Replace by August 23, 2026
FMCSA removed TRUCKSTAFF ELD (model TRKSF, identifier TRS227) from its list of registered electronic logging devices for failing to meet the minimum requirements in 49 CFR Part 395, Appendix A to Subp
Read post
Jun 1, 2026
OSHA Cites Georgia Piggly Wiggly Franchisee $196K After Meat Grinder Amputation — Willful Machine Guarding Violation
OSHA cited RBG Foods Inc., operating a Bowden, Georgia Piggly Wiggly supermarket, after a meat department worker lost four fingers when a co-worker stepped on a commercial grinder's foot-control pedal
Read post
May 27, 2026
DOL Cancels 2026 Civil Penalty Inflation Adjustment — OSHA Maximum Penalties Stay at 2025 Levels
For the first time since annual adjustments began under the Federal Civil Penalties Inflation Adjustment Act Improvements Act of 2015, the Department of Labor will make no inflation adjustment to its
Read post
Sources & methodology
Every form in this library is a public-domain government document. BlueHive mirrors the most current revision we can verify, links back to the issuing agency, and records the date of the last source check. We do not modify, fill, or annotate the official PDFs.
- Verified forms
- 38
- Agencies cited
- 32
- Last updated
- 2026-07-07
Important Legal Notice
The regulatory information presented on BlueHive Compliance Watch is provided for general informational purposes only and should not be construed as legal advice. While we strive to maintain accurate and up-to-date information, regulations can change rapidly and may be subject to interpretation.
You should always:
- Consult with qualified legal counsel before making compliance decisions
- Verify information with official government sources
- Review the full text of any regulation cited herein
- Consider jurisdiction-specific requirements that may apply to your organization
BlueHive Health, LLC makes no warranties or representations about the accuracy, completeness, or timeliness of this information. We are not responsible for any actions taken or not taken based on this content.
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