Use this as a private worksheet
Organize the claim by document type instead of keeping one unsorted file. This is not an official agency or court form.
Claim and agency papers
- ☐ Injury report: ______________________________
- ☐ Claim form: ______________________________
- ☐ Acceptance or denial notice: ______________________________
- ☐ Hearing/appeal papers: ______________________________
Medical
- ☐ First treatment note: ______________________________
- ☐ Diagnostic tests: ______________________________
- ☐ Work restrictions: ______________________________
- ☐ Referrals or authorization decisions: ______________________________
Work and wages
- ☐ Job description: ______________________________
- ☐ Pay stubs: ______________________________
- ☐ Schedules: ______________________________
- ☐ Light-duty offers: ______________________________
Communication
- ☐ Employer messages: ______________________________
- ☐ Insurer/adjuster letters: ______________________________
- ☐ Agency correspondence: ______________________________
- ☐ Call log: ______________________________
Privacy reminder
Keep sensitive medical, wage, claim-number, and employment information private. Share it only with appropriate official agencies, licensed professionals, insurers, treating providers, or other people who legitimately need it for the claim.
Use the worksheet with the source records
- Enter dates from the notice, medical record, payment record, or message instead of memory.
- Leave an item blank when it is unknown; do not guess to complete the page.
- Keep a private copy and update it after a new notice, appointment, payment, or work-status change.
- Bring the worksheet and the supporting documents to an agency call or lawyer consultation.