TO: All Commonwealth Employees With Work-Related Injuries

SUBJECT: Panel Physician Selection Form

Any Commonwealth of Virginia employee injured in a work-related accident must report to one of the physicians recommended from a list of at least three physicians provided by your supervisor.

If you are an employee injured on the job and require immediate care, you should report to the nearest medical facility for treatment. After the initial treatment, you must select a physician from the list provided by your supervisor.


I have reviewed the panel of at least three physicians provided to me by my supervisor and have selected:

_____________________________ (Physician’s Name/Facility’s Name)

Date: _________________ __________________________________

Employee’s Signature

Date: _________________ __________________________________

Supervisor’s Signature

Submit completed form to Human Resources.