How to Fill Out California WCAB DWC-AD 100 (w/Examples) + FAQs

California DWC-AD Form 100 is the Employee’s Disability Questionnaire used by the Division of Workers’ Compensation Disability Evaluation Unit (DEU), and any injured worker scheduled for a permanent disability rating evaluation must fill it out and give it to the evaluating physician before the exam. The form lets the doctor understand your job, your injury, and your prior medical history so the report supports a fair permanent disability rating under Labor Code §4660.

The current version on the DWC forms page is dated REV. 11/2008, and even though the revision date looks old, this is still the form the DEU expects. The DEU processes roughly 70,000 summary ratings every year based in part on the answers you give on this two-page questionnaire, so a sloppy answer in one box can shave thousands of dollars off a permanent disability award.

• 📄 What DWC-AD 100 is, who must fill it out, and the statute behind it
• 🖊️ A field-by-field walkthrough of every box on pages 1 and 2
• 👥 Three full filled-out examples from real injured-worker scenarios
• 📬 How to deliver the form to your doctor, the DEU, and your claims administrator
• ⚠️ The most expensive mistakes filers make and how to avoid them

What the Form Is and Who Must File It

The DWC-AD 100 (DEU) Employee’s Disability Questionnaire is a two-page intake form that the DEU uses to gather the injured worker’s own description of the injury, the job, and the medical history. The doctor who performs your permanent and stationary (P&S) evaluation attaches your completed form to the medical-legal report and sends it to the DEU along with a copy to you and your claims administrator. The form is authorized under 8 CCR §10160 and the rating procedures in 8 CCR §10166, which let the DEU prepare summary and consultative ratings.

Anyone with an open California workers’ compensation claim who has been scheduled for a comprehensive medical-legal evaluation should fill it out. That includes injured workers represented by an applicant attorney, unrepresented workers being seen by a Qualified Medical Evaluator (QME) under Labor Code §4062.1, and represented workers being seen by an Agreed Medical Evaluator (AME). It is not required for a treating physician’s routine progress visit, but most evaluators want it before any P&S exam so they can write an accurate impairment narrative.

The form ties directly to your permanent disability under Labor Code §4658. The DEU rater reads your answers about job duties, prior injuries, and current limitations to apply the 2005 PDRS and the AMA Guides 5th Edition. If you leave the questionnaire blank or hand the doctor a sheet with one-word answers, the rater has to guess, and a guess almost always favors the side with better paperwork — which usually is not you.

Before You Start: Documents and Information You Need

Pull these items together before you sit down with the form. Hunting for them with a pen in your hand is how filers end up writing the wrong claim number or the wrong date of injury, both of which can disqualify the rating. The DWC injured worker guides recommend keeping all of this in one folder.

• Your DWC-1 claim form copy. This shows the official date of injury and claim number, and a mismatch with what the carrier has on file will delay your rating.
• Letters from your claims administrator. These contain the assigned claim number and the third-party administrator’s address, which the doctor needs.
• Your ADJ case number from EAMS. If your case has been filed at the WCAB, the ADJ number anchors the rating to your case file.
• Your Social Security number. The DEU uses the SSN to match your rating to past ratings; without it, the rater cannot apportion correctly.
• Your full mailing address with ZIP code. The summary rating is mailed to you, and a wrong ZIP delays delivery by weeks.
• Your employer’s legal name and the nature of the business. “Acme Inc.” plus “wholesale grocery distributor” is what the rater needs, not just “Acme.”
• A short written description of your job duties. Two or three sentences covering lifting, standing, repetitive motion, and equipment used.
• A list of every prior injury, surgery, or disability. Dates, body parts, and outcomes — this controls apportionment under Labor Code §4663.
• The name and address of your evaluating doctor. Pulled from the QME panel letter or AME agreement.
• Your appointment date and time. The form has a field for the scheduled exam date.

If any of these items is missing, do not leave the field blank — call your claims adjuster or your attorney’s office and get the data first, because a blank field is read by the rater as “no information,” which the DEU rating procedures treat as an absence of evidence.

Where to Get the Form and How to Access It

The official DWC-AD 100 lives on the DWC forms page under the Disability Evaluation Unit section, and the direct PDF is hosted at the dir.ca.gov server. Always download a fresh copy for each evaluation rather than reusing an old one, because the DEU sometimes posts a refreshed PDF with updated barcodes that EAMS reads more reliably.

You can also pick up the form in person at any DWC district office, and most QME and AME doctors keep a stack at reception. If your doctor’s office gives you the form, double-check that the bottom of each page reads DWC-AD form100 (DEU) (REV. 11/2008) so you know it is the current version. Anything older will be rejected by the DEU’s intake system.

The PDF is fillable in Adobe Acrobat Reader, which is the cleanest way to complete it because typed answers are easier for the DEU’s optical character reader. If you do not have Acrobat, print the form, fill it in with black ink in clear block letters, and avoid pencil because pencil does not scan. Pro per (unrepresented) workers can ask their assigned Information & Assistance officer for help completing it at no charge.

Step-by-Step: How to Fill Out DWC-AD 100 Line by Line

The form has two pages. Page 1 captures who you are, who your employer is, and your basic claim data. Page 2 asks open-ended questions about how the injury happened, what your job involved, and what prior injuries you have had. Every box matters, and the DEU rater reads each one when applying the 2005 Permanent Disability Rating Schedule.

First Name

This box asks for your legal first name as it appears on your Social Security card. Type or print your given name in clean block letters, and do not use a nickname or shortened version. Maria is correct; Mari is not, even if friends call you that.

A nuance arises if you go by a middle name in daily life — still write the legal first name here, because the DEU cross-references your SSN against the Social Security Administration. The most common mistake is writing a married first name versus a maiden first name when the SSN record has not been updated, which causes the rating to be returned to the doctor for correction. Many filers think the DEU will “figure it out” from context, but it will not; the system flags the mismatch automatically.

Last Name

Enter your current legal last name as it appears on your Social Security card. If you recently changed your name through marriage or divorce, use whichever name the SSA currently has on file, because the rating cross-checks against SSA records under 8 CCR §10166. Hernandez is what Maria writes if her SSA card still says Hernandez even though she is now married.

The most common edge case is a hyphenated last name — write it with the hyphen and no spaces, like Smith-Garcia. The biggest mistake is dropping the hyphen, which causes the DEU’s database to split the name into two words and lose the rating. Filers often think the form is “just for the doctor,” but the form follows the medical-legal report into the DEU’s system and becomes part of the official rating file.

MI (Middle Initial)

Write a single letter, no period needed if space is tight. If you have no middle name, leave the box blank rather than writing “N/A,” because the DEU’s scanner reads “N/A” as a literal middle initial of N. J is what Maria enters for Maria Jane Hernandez.

A quirky edge case: people with two middle names often try to cram both initials into the box. Write only the first one, because the field is one character wide. The mistake of writing “JM” gets truncated by the scanner and the rating ends up under the wrong filer profile. The misconception that middle initial is “optional fluff” is wrong — it is the tiebreaker the DEU uses when two injured workers share a last name and date of birth.

Street Address 1 / PO Box

This is your current mailing address where the DEU summary rating will be sent. Use leading blank spaces between numbers and street name as the form instructs, like 1234 Main Street. Do not abbreviate Street to St. unless you are running out of space, because the USPS-format readers prefer the spelled-out version.

If you have moved during the case, use your current address, not the address on the original DWC-1. The biggest mistake is using a workplace address — your employer’s mail clerk does not always forward DEU envelopes, and the rating can sit in a desk drawer for months. Many workers think they must use the address on file with the carrier; you do not, but you should also send a change-of-address notice to the claims administrator so both sides match.

Street Address 2 / PO Box

Use this line for an apartment number, suite, or PO Box if you have one. Apt 4B is correct; if your address has no second line, leave it blank. Do not write “none” or draw a line through it, because both confuse the OCR scanner.

The most common edge case is an address with both a street and a PO Box — put the street on line 1 and the PO Box here on line 2 only if you receive mail at both. The mistake of repeating the street address on line 2 causes the envelope to be returned by USPS as undeliverable. People often believe a PO Box is suspicious to government agencies, but the DEU accepts PO Boxes without question.

City, State, Zip Code

Write the city in full, the two-letter state abbreviation, and a five-digit ZIP. Fresno, CA, 93721 is the correct format. ZIP+4 is welcome but not required.

The edge case is a small unincorporated community whose mail goes through a larger post office — use the post office name, not the community name, otherwise USPS cannot deliver. The mistake of writing the wrong ZIP is the single most common reason summary ratings arrive weeks late. Many filers think the DEU will “look up” the right ZIP, but the DEU just prints what you write on the envelope.

International Address

Most filers leave this blank because they live in California. If you have moved out of the country during the case, use this line for the foreign-format address with country name. Avenida Reforma 222, Mexico City, Mexico is what an injured worker who returned to Mexico would write.

The edge case is a worker stationed temporarily abroad — still use a domestic address if you have one, because the DEU’s mailing service is faster within the US. The mistake of writing a foreign address when you still have a US mailing address slows the rating by weeks. Filers sometimes think a foreign address voids their California claim; it does not, because Labor Code §3600.5 preserves jurisdiction.

Date of Birth

Use the MM/DD/YYYY format the form prints above the box. 03/14/1985 is what Maria Hernandez writes. Do not use dashes, slashes optional but recommended.

A common edge case is a filer who only has a year-of-birth on identification documents from another country — use 01/01/YYYY only if no exact date exists, and tell your attorney so they can document the issue. The mistake of writing the date European-style as DD/MM/YYYY swaps month and day, which can age you by years in the rater’s calculation. Filers sometimes believe DOB is “just demographic” — it is not, because age modifies your final permanent disability rating under the 2005 PDRS age and occupation adjustments.

Date of Injury

Enter the official date of injury from your DWC-1 in MM/DD/YYYY format. For specific traumatic injuries, this is the date the accident happened. 06/22/2024 is what Carlos enters for a back injury that occurred lifting a pallet on June 22, 2024.

For cumulative trauma injuries, the date of injury is the date set under Labor Code §5412, which is the date you knew or should have known the injury was work-related and caused disability. The mistake of using the date you first noticed pain, instead of the §5412 date, can shift you to a different rating schedule entirely. Filers often think they can pick “the worst day” — they cannot, because the date is a legal finding tied to your claim file.

SSN (Numbers Only)

Enter all nine digits of your Social Security number with no dashes. 123456789 is the correct format. The form’s scanner ignores dashes, but typing them sometimes triggers a field-length error in the fillable PDF.

The edge case is an undocumented worker without an SSN — use your ITIN if you have one and tell your attorney, because Farmer Bros. Coffee v. WCAB confirms eligibility regardless of immigration status. The mistake of using a fake SSN is fraud under Insurance Code §1871.4 and will tank your case. Filers sometimes think omitting the SSN protects privacy; it does not, because the DEU encrypts the field, and an empty SSN simply blocks the rating.

Employer

Write the employer’s full legal name as shown on your paystubs, not the trade name on the storefront. ABC Logistics, Inc. is correct; ABC alone is not. Include “Inc.,” “LLC,” or “Corp.” if it applies.

The edge case is a worker employed by a staffing agency placed at a host employer — write the staffing agency, because that is the entity insured for your claim, and note the host employer in the “Nature of Business” field. The mistake of naming only the host employer can route your rating to the wrong carrier file. Filers often think the “boss they reported to” is the employer — sometimes it is not, especially in temp and gig arrangements.

Nature of Employer’s Business

Describe what the employer actually does in plain English. Wholesale grocery distribution or residential roofing contractor are good examples. The DEU uses this to assign your occupation group number in the PDRS occupation chart, which can change your final rating by 5 to 15 points.

The edge case is a multi-line business — describe the line of business you worked in, not the parent company’s broadest category. The mistake of writing something generic like “company” or “services” loses you occupation-group adjustments worth real money. Filers sometimes think this is small talk for the doctor; it is actually a rating input the DEU codes directly.

Claim Number 1 (and 2 through 5)

Enter the carrier’s claim number exactly as it appears on the carrier’s letterhead. WC-2024-558821 is an example. Use Claim Number 2 through 5 only if you have multiple injuries with multiple claim numbers being evaluated together.

The edge case is a worker whose carrier reissued a claim number after a transfer — use the most recent number and list the old one in the next box. The mistake of writing the ADJ number here instead of the carrier number causes the DEU to fail to match the rating to the carrier file. Filers often confuse the WCAB ADJ number with the carrier claim number; they are different, and the DEU needs the carrier number here.

How was your evaluating doctor selected?

Page 2 starts with this checkbox. The choices map to QME panel, AME agreement, treating physician, DWC list, or Other (explain). Check exactly one, because checking two confuses the rater about which procedural track your case is on.

The edge case is a represented worker who originally had a panel QME but switched to an AME — check AME, because that is the doctor who is actually evaluating you. The mistake of checking “Other” without explanation triggers a development letter and delays the rating. Filers sometimes think this question is just demographic; it is actually how the rater knows whether to apply Labor Code §4061 (unrepresented) or §4062.2 (represented) procedures.

Name of the Doctor Who Will Be Doing the Evaluation

Write the doctor’s full name and credential. Anil Patel, M.D. is what Carlos writes for his orthopedic QME. Include the office address on the line provided, copied from the QME appointment letter.

The edge case is a multi-specialty exam where two doctors will see you on the same day — list the lead evaluator only, and let your attorney handle the second report. The mistake of writing the office staff coordinator’s name instead of the doctor’s name routes the form into the wrong file. Filers sometimes think any office contact is fine — only the evaluating physician’s name belongs here.

What were your job duties at the time of your injury?

This is one of the most rating-relevant fields on the form. Describe your physical tasks in two to four sentences, mentioning lifting weights, postures, repetitive motion, and tools. I loaded and unloaded boxes weighing 25 to 75 pounds for eight hours a day, climbed ladders, and operated a manual pallet jack is the level of detail the rater needs to assign your occupation group.

The edge case is a worker whose duties changed in the months before injury — describe the duties of the date of injury, not the earlier role. The mistake of writing one-word answers like “warehouse” costs you occupation-adjustment points. Filers often think the doctor will fill this in for them — the doctor will not, and missing detail here is interpreted as light duty.

What is the disability resulting from your injury?

Describe what your body cannot do now that it could do before. Cannot lift more than 10 pounds, cannot stand more than 20 minutes, lost grip strength in right hand is more useful than “back hurts.” Tie each limitation to a body part and a function, because the AMA Guides rate function loss.

The edge case is a worker with multiple body parts injured — list each one separately and the limitation tied to it. The mistake of writing only “pain” understates impairment, because pain alone has a low rating ceiling under the AMA Guides 5th Edition. Filers often believe being “tough” by minimizing symptoms helps their case; in workers’ comp it does the opposite, because the rating is built from documented limitations.

How does this injury affect you in your work?

Tie your limitations directly to job tasks. I cannot climb the ladder anymore, cannot lift cases of product, cannot stand at the line for a full shift is the format. The rater uses this to apply the diminished future earning capacity modifier under the 2005 PDRS.

The edge case is a worker who has returned to modified duty — describe the original job duties you cannot do, not just the current modified ones. The mistake of writing “I am working now” without context tells the rater you have no work restrictions. Filers sometimes think working is a strike against their claim; it is not, because permanent disability and the ability to work are separate questions.

Have you ever had a disability as a result of another injury or illness?

Answer Yes or No truthfully. If yes, complete the date and description fields below. Yes — 2017 left knee meniscus tear, surgery and 6 weeks off work is a clean example.

The edge case is a non-industrial condition like a car accident or a sports injury — list it, because Labor Code §4663 requires apportionment between industrial and non-industrial causes. The mistake of hiding a prior injury is the single most damaging move on this form, because if the doctor finds it in your medical records anyway, your credibility is destroyed. Filers often believe disclosing prior injuries hurts the case; well-documented apportionment usually protects more than it harms.

When is your examination scheduled?

Write the date of the upcoming evaluation in MM/DD/YYYY format. 09/15/2026 is what Maria writes for her panel QME. The doctor uses this to confirm the visit and chart the questionnaire to the correct exam.

The edge case is a rescheduled appointment — write the new date, not the original one. The mistake of writing the date you filled out the form instead of the appointment date causes the doctor’s office to file the questionnaire in the wrong slot. Filers sometimes leave this blank because “the doctor knows when the appointment is” — the form follows the report, and a blank date here looks like missing data to the rater.

Signature

Sign at the bottom of page 2. The form is not under penalty of perjury, but the doctor relies on it as your sworn personal history, and lying here can be used against you under Insurance Code §1871.4. Sign in blue or black ink.

The edge case is a worker who cannot sign because of a hand injury — make a mark and have a witness initial it, then have your attorney note the accommodation. The mistake of letting a family member sign for you is forgery and will void the rating. Filers sometimes believe the signature is a formality; in reality, the doctor’s report often quotes your answers verbatim, and your signature authenticates them.

Date

Write the date you signed the form, in MM/DD/YYYY format, on the same day you hand the form to the doctor. 09/15/2026 is what Carlos enters at his appointment.

The edge case is a worker filling the form out a week early at home — use the day you actually sign it, and resign on the day of the exam if the doctor asks. The mistake of leaving the date blank invites the doctor’s staff to fill it in, which can later be used to challenge the timing of disclosures. Filers sometimes write a “future” date to match the appointment; do not — date it the day you sign.

Three Filled-Out Examples Using Real Scenarios

These three named injured workers show how DWC-AD 100 looks when completed end-to-end. Each scenario reflects one of the most common patterns the DEU sees.

Scenario 1: Maria Hernandez — Warehouse Back Injury, Panel QME

Maria is a 41-year-old warehouse picker who hurt her low back lifting a 65-pound case. She is unrepresented and was assigned a panel QME under Labor Code §4062.1.

Form Section	What Maria Enters
First Name / Last Name / MI	Maria / Hernandez / J
Street Address 1	1422 Olive Avenue
City / State / Zip	Fresno / CA / 93728
Date of Birth	03/14/1985
Date of Injury	06/22/2026
SSN	123456789
Employer / Nature of Business	ABC Logistics, Inc. / Wholesale grocery distribution
Claim Number 1	WC-2026-558821
Doctor selection	QME panel
Job duties	Picked and packed orders, lifted boxes 25–75 lbs, used pallet jack 8 hrs/day
Prior disability	No
Exam date / Signature	09/15/2026 / Maria J. Hernandez

Scenario 2: Carlos Ramirez — Roofer With Cumulative Trauma, AME

Carlos is a 52-year-old residential roofer with cumulative trauma to both shoulders and his right knee. He is represented and his attorney agreed on an AME with defense counsel.

Form Section	What Carlos Enters
First Name / Last Name / MI	Carlos / Ramirez / (blank)
Street Address 1 / Apt	876 Sunset Blvd / Apt 12
City / State / Zip	Bakersfield / CA / 93301
Date of Birth	07/02/1973
Date of Injury	11/10/2025 (CT date under §5412)
Employer / Nature of Business	Sierra Roofing LLC / Residential roofing contractor
Claim Numbers 1 and 2	SR-25-001148 / SR-25-001149
Doctor selection	AME
Doctor name	Anil Patel, M.D.
Job duties	Climbed ladders, carried 50 lb shingle bundles up two stories, kneeled 6 hrs daily
Prior disability	Yes — 2017 left knee meniscus tear, surgery, 6 weeks off work
Exam date / Signature	10/04/2026 / Carlos Ramirez

Scenario 3: Janet Liu — Office Worker, Carpal Tunnel, Treating Physician Eval

Janet is a 58-year-old administrative assistant with bilateral carpal tunnel syndrome. She is unrepresented and her primary treating physician (PTP) is also her evaluator.

Form Section	What Janet Enters
First Name / Last Name / MI	Janet / Liu / M
Street Address 1	301 Bay Street
City / State / Zip	Oakland / CA / 94607
Date of Birth	11/30/1967
Date of Injury	02/15/2025 (CT)
Employer / Nature of Business	Bay Tech Solutions, Inc. / Software consulting
Claim Number 1	BTS-25-7711
Doctor selection	Treating physician
Job duties	Typed 6–8 hrs/day, used mouse continuously, no ergonomic accommodations
Disability description	Numbness both hands, dropping objects, cannot type more than 30 minutes
Prior disability	No
Exam date / Signature	07/22/2026 / Janet M. Liu

How to File the Completed Form

DWC-AD 100 is not filed at the WCAB the way an Application for Adjudication is. Instead, you deliver the completed form to your evaluating physician, who attaches it to the medical-legal report and sends it to the DEU along with the report. You also keep a copy and send one to your claims administrator under 8 CCR §10629 service rules.

In person at the appointment. This is the most common channel. Bring two printed copies — one for the doctor and one for your file. There is no fee. Processing time is the same as the medical-legal report, which under Labor Code §4062.5 is 30 days from the exam. Your proof-of-filing is the doctor’s office intake stamp on your copy.

By mail to the doctor’s office before the exam. Mail to the address on the QME panel letter or AME agreement letter, using certified mail with return receipt. There is no fee, but postage costs around $5. Processing time is 7–10 days for the office to receive and chart. Keep the green USPS return-receipt card as your proof-of-filing.

By email or fax to the doctor’s office. Many QME and AME offices accept the form by email or fax, especially for appointments scheduled within 7 days. Confirm the email or fax number on the appointment letter. There is no fee. Processing time is same-day. Save the “sent” confirmation as proof-of-filing.

Through your attorney’s e-file system. If you are represented, the law firm uploads the form to its case management system and serves it on the carrier and doctor electronically through services like JET File when applicable. There is no fee. Processing time is same-day. Proof-of-filing is the system’s transmission receipt.

At an Information & Assistance office. Pro per workers can bring the form to a local I&A officer, who will help check it for completeness and forward it. There is no fee. Processing time is one business day. Proof-of-filing is the I&A office stamp.

What Happens After You File

Once the doctor receives DWC-AD 100, the office charts it into your file and the evaluator reads it before — or sometimes during — your appointment. The evaluator quotes from your answers throughout the medical-legal report, especially in the history-of-injury and prior-history sections, and your job-duties description drives the work-restrictions analysis under the AMA Guides 5th Edition.

After the exam, the doctor has 30 days under Labor Code §139.2(j)(1) to issue the medical-legal report. The doctor sends the report and your DWC-AD 100 to the DEU, the claims administrator, and you. The DEU then issues a summary rating within roughly 20 days for unrepresented cases under Labor Code §4061(c) or a consultative rating for represented cases.

If you disagree with the summary rating, you have 30 days to request reconsideration by the DEU or to file an Application for Adjudication of Claim at the WCAB. Failure to act within 30 days makes the rating presumptively correct under 8 CCR §10160. If you settle on a Compromise & Release or Stipulations with Request for Award based on the rating, the questionnaire becomes part of the permanent case record.

Mistakes to Avoid When Filling Out the Form

Each of these errors has cost real injured workers real money. The DEU rater cannot fix what you wrote; you live with the consequences.

• Writing a nickname instead of legal first name. The DEU’s SSN cross-check fails and your rating gets returned for correction.
• Using DD/MM/YYYY for dates. The rater applies the wrong age modifier and your final rating drops.
• Hiding a prior injury. The doctor finds it in your records anyway, your credibility tanks, and apportionment becomes punitive.
• Listing only “pain” in the disability box. The AMA Guides cap pain-only impairment far below function-loss impairment, so you under-rate yourself.
• Writing one-word job duties. The DEU assigns the lowest occupation group, costing you 5 to 15 rating points.
• Putting the WCAB ADJ number in the carrier-claim-number box. The DEU cannot match the rating to the carrier file and processing stops.
• Leaving the SSN blank. The DEU’s intake system rejects the questionnaire for missing identifier.
• Naming the host employer instead of the staffing agency. The carrier on file does not recognize the claim and the rating routes nowhere.
• Filling in a future signature date. Creates a paper-trail problem if the doctor’s office stamps it on a different day.
• Letting a family member sign for you. Constitutes forgery and voids the rating.
• Using pencil on a printed form. The DEU scanner cannot read pencil and treats the field as blank.
• Skipping the “exam date” field. The doctor’s office charts the form into the wrong appointment slot.

Do’s and Don’ts

These quick rules separate clean filings from sloppy ones.

• Do download a fresh PDF from the DWC forms page for every evaluation, because revisions occasionally update the barcode.
• Do type your answers in Acrobat Reader when possible, because typed entries OCR cleanly and reduce data-entry errors.
• Do describe job duties with weights, durations, and postures, because the rater uses this to assign the occupation group.
• Do disclose every prior injury truthfully, because apportionment under Labor Code §4663 is far gentler when documented than when discovered.
• Do keep a signed copy in your records, because the DEU sometimes asks you to confirm what you submitted.
• Do send a courtesy copy to your claims administrator, because it heads off disputes about service.
• Don’t abbreviate beyond what the form invites, because the DEU’s scanner expects standard formatting.
• Don’t sign the form before you have read every box, because your signature authenticates the entire questionnaire.
• Don’t let the doctor’s staff fill in answers for you, because the questionnaire is your statement.
• Don’t ignore the international address line if you have moved abroad, because the rating mailing depends on it.
• Don’t treat the questionnaire as informal, because the doctor quotes from it in a sworn medical-legal report.
• Don’t rely on memory for dates and claim numbers, because a single wrong digit can derail the rating.

Pros and Cons of Filing on Your Own vs. With Help

Many injured workers handle DWC-AD 100 themselves, while others get help from an attorney or I&A officer. Here is the tradeoff.

Pros of filing on your own: – No legal fee comes out of your pocket or your award. – Faster turnaround because you do not wait for an attorney’s review cycle. – Direct control over how your job duties and prior history are described. – Privacy because no third party sees sensitive medical history. – Simple cases like a single body part with no priors rarely need help.

Cons of filing on your own: – Easy to underrate yourself by writing “pain” instead of functional limitations. – Apportionment traps when you do not understand how to disclose priors strategically. – Occupation-group errors because most workers do not know the PDRS occupation chart drives a 5–15 point swing. – Lost deadlines to dispute the rating, because you may not realize a 30-day clock is running. – No safety net if the carrier challenges your answers later.

FAQs

Is DWC-AD 100 the same as a Notice of Representation?

No. DWC-AD 100 is the Employee’s Disability Questionnaire used by the DEU; the Notice of Representation is a separate filing under 8 CCR §10400 for attorneys.

Do I have to fill it out before every doctor visit?

No. You only fill it out for medical-legal evaluations like QME, AME, or P&S exams that will result in a permanent disability rating, not for routine treatment visits.

Can my attorney fill it out for me?

No. Your attorney can guide you, but the answers must be your own personal statements because the doctor relies on the questionnaire as your history.

Is the form filed at the WCAB?

No. The form is delivered to the evaluating doctor, who attaches it to the medical-legal report sent to the DEU, the claims administrator, and you.

Do I write my maiden name or married name in the Last Name box?

Yes — write whichever name matches your current Social Security card, because the DEU cross-checks against SSA records.

What if I don’t know my exact date of injury for a cumulative trauma claim?

Yes, use the date set under Labor Code §5412, which is when you knew the injury was work-related and disabling, and ask your attorney if uncertain.

Should I leave the SSN box blank for privacy?

No. A blank SSN blocks the DEU intake system, and the field is encrypted in the agency database.

Do I list non-industrial prior injuries like a car accident?

Yes. Disclose every prior injury, because Labor Code §4663 requires apportionment and undisclosed priors damage credibility.

Is the form signed under penalty of perjury?

No, the DWC-AD 100 itself is not under penalty of perjury, but lying can still be charged as fraud under Insurance Code §1871.4.

Can I fill out the form in Spanish or another language?

Yes, you can write answers in your native language, but ask your attorney or an I&A officer about translation so the rater can read it.

Does the form expire if I do not use it within a certain time?

No revision-date expiration applies, but always download a fresh copy from the DWC forms page before each evaluation in case the agency updates the barcode.

Do I need to fill in Claim Number 2 through 5 if I only have one claim?

No. Leave Claim Numbers 2 through 5 blank if you only have one claim; only use them when multiple injuries with separate claim numbers are being evaluated together.

What happens if the doctor loses my completed form?

Yes, this happens — bring two copies to the appointment, send one by certified mail in advance, and keep your stamped copy as proof-of-filing.

Is there a fee to file DWC-AD 100?

No. There is no filing fee for DWC-AD 100 at the doctor’s office, the DEU, or the WCAB.

Can I correct a mistake after I have already given the form to the doctor?

Yes. Submit a corrected form to the doctor’s office in writing as soon as possible and ask that it be attached to the medical-legal report alongside the original.