Attending Physician's Supplementary Report

(Longshore and Harbor Workers' Compensation Act,

As Extended)

U.S. Department of Labor

Office of Workers' Compensation Programs

https://www.dol.gov/agencies/owcp/dlhwc

INSTRUCTIONS: Use this form to make progress reports and to make a final report when the patient is discharged. 

Progress reports should be submitted about every thirty days, the original to the District Director (See Item 19. on page 

2) and one copy to the insurance carrier or self-insured employer. Please answer all questions fully. If a question is not 

applicable, enter "NA". The exact point of amputation or other permanent partial impairment must be known to 

determine compensation the injured is entitled to receive. If preferred, physician may submit a narrative report covering 

all information requested on this form. Use "Remark" on page 2 of form if more space is needed for any answer.

OMB No. 1240-0014

OWCP No.

Carrier's No.

7a. Have you filed a previous report giving history? 

 Yes- skip to Item 8 No-Answer 7b and 7c

7b. State how many injuries occurred and give source of 

information. (If claim is for occupational disease, include 

occupational history and date of onset of related 

symptoms)

7c. Was employee previously under the care of another physician for this injury?

 No Yes- Give Physician's name and 

address and reason for transfer

8. Is there any history or evidence of pre-existing injury, disease or physical impairment?

9a. Present condition (include diagnosis, subjective 

complaints, objective findings, and any changes of 

condition since last report.)

9b. If employee was hospitalized since last report, indicate and give name and address 

of hospital.

10a. Describe treatment provided

10b. Date of first treatment 10c. Date of most recent treatment 10d. Has treatment been terminated?

No Yes- Indicate reason

10e. Are you continuing treatment? 10f. If treatment is continuing, estimate probable 

duration

This report is authorized by 33 U.S.C. 907(b). While you are not required to respond on this form, your cooperation is needed to insure that the 

injured's workers' compensation case is properly processed by the U.S. Department of Labor. This form is used to request medical information which 

will be used to determine an injured worker's entitlement to compensation and medical benefits.

Form LS-204

Rev. Nov 2023

3. Name of Injured employee

 Progress Final

1. Type of Report (Mark X one) 2. Date of Injury (mm/dd/yyyy)

4. Employee's home address

5. Name of employer 6. Name of insurance carrier

No Yes

Injured Employee's Telephone Number

Expires: 11/30/2026
11. Will the injury result in permanent restriction, total or partial loss of function or a part or member, or permanent disfigurement of the head, face, or 

neck, or some other part of the body which will handicap the employee in securing or maintaining employment?

No Yes-Describe

12. Is employee working? 13. When do you estimate employee can

Yes No

 a. Resume limited work of any kind? b. Resume regular work?

 Date (mm/dd/yyyy) Date (mm/dd/yyyy)

15. In your opinion, was the occurrence described above (or in the previous report which gave this information) the competent producing cause of the 

injury and disability?

Yes No

16. Is rehabilitation treatment or service or evaluation 

recommended?

17. If rehabilitation treatment or services or evaluation is recommended, has referral 

been made?

18. Remarks 19. Send the original of your report to:

U.S. Department of Labor 

Office of Workers' Compensation Programs 

Division of Federal Employees’, Longshore and Harbor Workers' Compensation 

400 West Bay Street, Suite 63A, Box 28 

Jacksonville, VL 32202

20. Name of attending physician (Type or Print) 21. Signature of physician

22. Address of Physician

The Privacy Act of 1974, as amended (5 U.S.C. 552a) section 901 of Title 33 to the US Code and 33 U.S.C. 907 (b) authorize collection of this 

information. The purpose of this information is to determine an injured worker's entitlement to compensation and medical benefits under the 

Longshore and Harbor Workers' Compensation Act (LHWCA). Completion of this form is not mandatory; however, failure to provide the information 

may result in the loss of compensation benefits. Additional disclosures of this information may be to: (1) the employer which employed the claimant at 

the time of injury, or to the insurance carrier or other entity which secured the employer's compensation liability. (2) physicians and other medical 

service providers for use in providing treatment or medical/vocational rehabilitation, making evaluations and for other purposes relating to the medical 

management of the claim. (3) the Department of Labor's Office of Administrative Law Judges (OALJ), or other person, board or organization, which is 

authorized or required to render decisions with respect to the claim or other matter arising in connection with the claim. (4) Federal, state and local 

agencies for law enforcement purposes, to obtain information relevant to a decision under the LHWCA to determine whether benefits are being and 

have been paid properly, and where appropriate, to pursue salary/administrative offset and debt collection actions required or permitted by law. (5) 

Failure to disclose all requested information may delay the processing of the claim, the payment of benefits, or may result in an unfavorable decision 

or reduced level of benefits. 

 PRIVACY ACT STATEMENT

23. Telephone Number of Physician 24. Date of Report

 DO NOT SEND COMPLETED FORMS TO THIS OFFICE.

 Public Burden Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a 

valid OMB control number. Public reporting burden for this collection of information is estimated to average 30 minutes per response, including time 

for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of 

information. Use of this form is optional, however furnishing the information is required in order to obtain and/or retain benefits. (33 U.S.C. 907 6). 

Send comments regarding this burden estimate or any aspect of this collection of information, including suggestions for reducing this burden, to the U.

S. Department of Labor, 200 Constitution Avenue, NW, Room S-3524, Washington, D.C. 20210, and reference the OMB Control Number.

14. If employee is unable to do his/her regular work, but can do limited work, specify work limitations due to this injury.

Yes- Explain No- Explain Yes- To whom? No- Explain

Form LS-204 

Rev. Nov 2023 

Page 2