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Physician: Date of Physical Exam: Address: Date This Form Completed: Telephone:. Practitioner's Report on Accident or Industrial Disease in Lieu of Testimony ; Document Number: WKC-16-B-E ; Description: This form is to be used for litigation.Practitioner Disease Report Form. Complete the following information to notify the Florida Department of Health of a reportable disease or condition. This report provides a framework that can be used to analyze internal audit professional ethics and related pressures. In these situations, you may complete the Online Reporting Form yourself. Student's health condition and their capacity to complete academic requirements. Published biennially, this report provides the most current data available about active physicians and physicians in training. Approximately 47 States, the District of. It is not necessary to answer the following questions if completing a report for a follow-up visit (form 11NP).