Newsline No. 40-09
July 22, 2009
Division of Workers’ Compensation posts qualified medical evaluator forms in Spanish
The Division of Workers’ Compensation (DWC) has posted on its Web site a Spanish-language version of the qualified
medical evaluator (QME) panel request form for unrepresented employees (QME Form 105), including instructions on
how to use Form 105 at http://www.dir.ca.gov/dwc/FORMS/QMEForms/QMEForm105Spanish.pdf.
Additionally, an example with Spanish language instructions on how to complete the Employee’s Permanent Disability
Questionnaire (DWC-AD Form 100 [DEU]) can be found at http://www.dir.ca.gov/dwc/FORMS/EAMS%
20Forms/DEU/DEU100Spanish.pdf.
The forms can be downloaded or printed from the DWC Web site at no charge and are in Spanish. However, the user is
directed to complete the answers on the forms in English.
The division is hopeful that the Spanish-language versions of these forms will make the QME process easier to
understand for injured workers and employers who are primarily Spanish-speaking.
###
July 22, 2009
Division of Workers’ Compensation posts qualified medical evaluator forms in Spanish
The Division of Workers’ Compensation (DWC) has posted on its Web site a Spanish-language version of the qualified
medical evaluator (QME) panel request form for unrepresented employees (QME Form 105), including instructions on
how to use Form 105 at http://www.dir.ca.gov/dwc/FORMS/QMEForms/QMEForm105Spanish.pdf.
Additionally, an example with Spanish language instructions on how to complete the Employee’s Permanent Disability
Questionnaire (DWC-AD Form 100 [DEU]) can be found at http://www.dir.ca.gov/dwc/FORMS/EAMS%
20Forms/DEU/DEU100Spanish.pdf.
The forms can be downloaded or printed from the DWC Web site at no charge and are in Spanish. However, the user is
directed to complete the answers on the forms in English.
The division is hopeful that the Spanish-language versions of these forms will make the QME process easier to
understand for injured workers and employers who are primarily Spanish-speaking.
###
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