STATE OF CALIFORNIA
Division of Workers’ Compensation
PRIMARY TREATING PHYSICIAN’S PERMANENT AND STATIONARY REPORT (PR-3)
This form is required to be used for ratings prepared pursuant to the 1997 Permanent Disability Rating Schedule. It
is designed to be used by the primary treating physician to report the initial evaluation of permanent disability to the
claims administrator. It should be completed if the patient has residual effects from the injury or may require future
medical care. In such cases, it should be completed once the patient’s condition becomes permanent and stationary.
This form should not be used by a Qualified Medical Evaluator (QME) or Agreed Medical Evaluator (AME)
to report a medical-legal evaluation.
Last Name ______________________ Middle Initial ____ First Name __________________ Sex___ Date of Birth ________
Address ______________________________________________ City _______________________ State _____ Zip _______
Occupation ___________________________ Social Security No. _____________________ Phone No.__________________
Name ____________________________________________ Claim No. _____________________ Phone No._____________
Address __________________________________________ City __________________________ State _____ Zip ________
Name ____________________________________________________________________ Phone No. ___________________
Address _______________________________________ City _________________________ State ___________ Zip ______
You must address each of the issues below. You may substitute or append a narrative report if you require
additional space to adequately report on these issues.
Date of Injury_____________ Last date _____________ Date of current _______________ Permanent & __________
Date worked Date examination