What this form is for
Primary treating physician's permanent and stationary report * 1997 permanent disability rating schedule
Official file
Published by the Division of Workers' Compensation. This page does not replace the form — it points at the state's PDF and, where the form is what a panel actually ruled on, quotes that ruling.
How to fill a DWC form →Source: dir.ca.gov/dwc/forms.html. Unofficial guide — the PDF on that site is the form.
What the Appeals Board did with this
Decisions of the Workers' Compensation Appeals Board that turned on this kind of filing. Each quotes the passage it turned on and links to the official PDF.
- ADJ10896001 · 2026-06-18 · Oxnard District OfficePermanent disability ratingapplicant prevailed
Determinative passage · p.14Here, a careful review of the medical reporting in this matter reveals that the apportionment opinions provided by both PQME Dr. Brooks and PQME Dr. Tirmizi fail to meet this rigorous evidentiary standard. The apportionment analysis proffered by PQME Dr. Brooks regarding applicant's thoracic and lumbar spine relies upon generalized factors rather than a precise medical explanation of causation. PQME Dr. Brooks assigned 75% nonindustrial apportionment to both spinal regions, attributing this allocation to applicant's mild degenerative MRI findings, his 16 years of previous employment in the construction industry, his participation in sports activities, and his limited 60-day tenure with defendant. PQME Dr. Brooks justified this determination by concluding that a single specific injury likely did not cause the total impairment and positing that applicant likely would have developed 75% of the impairment even absent the October 28, 2016 injury. This rationale is fundamentally speculative. The mere fact that a medical report assigns approximate percentages of industrial and nonindustrial causation does not make the report reliable medical evidence by itself. By relying on applicant's prior work history and sports activities
The apportionment opinions by PQME Dr. Brooks and Dr. Tirmizi lacked sufficient medical explanation and were speculative, so no apportionment was found. The permanent disability was found to be 27%.
Official decision · page 14 → - ADJ15295325 · 2026-06-15 · Sacramento District OfficePermanent disability ratingapplicant prevailed
Determinative passage · p.1Applicant seeks reconsideration of a workers' compensation administrative law judge's (WCJ) Findings of Fact and Award of March 12, 2026, wherein it was found that while employed as a correctional officer during a cumulative period ending on June 19, 2021, applicant sustained industrial injury to the neck causing permanent disability of 40% after apportionment. In finding permanent disability of 40%, it was determined that applicant did not prove that she was not amenable to vocational rehabilitation and did not prove that she was unable to compete in the open labor market. Additionally, it was found that, pursuant to the apportionment determination of qualified medical evaluator, physical medicine specialist Brian Karvelas, M.D., that 20 percent of applicant's permanent disability was caused by factors other than the industrial injury. Therefore, applicant's overall 48% permanent disability was apportioned, and it was found that applicant was entitled to an award of 40% compensable permanent disability.
The Board found that the applicant did not rebut the scheduled rating but that the apportionment evidence by Dr. Karvelas was not substantial medical evidence, thus granting an unapportioned 48% permanent disability award.
Official decision · page 1 → - ADJ118647 · 2026-06-08 · San Diego District OfficePermanent disability ratingdefendant prevailed
Determinative passage · p.8After reviewing all the evidence presented, including the testimony of the current claims adjuster and the Applicant, the undersigned determined there was no substantial medical evidence on the issue of Applicant's permanent disability for her admitted injuries and ordered that parties to undergo the Panel Qualified Medical process. Although admittedly it is unclear, Applicant does
Applicant failed to prove permanent disability or apportionment for her industrial injury to the neck and bilateral shoulders by a preponderance of the evidence.
Official decision · page 8 → - ADJ11324273 · 2026-06-01 · Oxnard District OfficePermanent disability ratingdefendant prevailed
Determinative passage · p.1Applicant filed a Petition for Reconsideration (Petition) on March 16, 2026, of the workers' compensation administrative law judge (WCJ)'s February 17, 2026, Joint Findings, Award & Order (FA&O), in which, as relevant here, the WCJ found that applicant sustained 57% disability in ADJ11728160, the cumulative claim.
The WCAB found no substantial medical evidence to rebut the AMA Guides impairment ratings and denied the claim for 100% disability under the presumption of total disability for loss of both hands or use thereof.
Official decision · page 1 →