This government document is issued by Industrial Commission for use in Idaho
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https://www.google.com/url?client=internal-element-cse&cx=017559489489848514908:0srzyzltlhf&q=https://iic.idaho.gov/wp-content/uploads/2019/04/IC-Form-1023.pdf&sa=U&ved=2ahUKEwiagKid5P2GAxW-BNsEHdViC2kQFnoECAMQAQ&usg=AOvVaw2s5PI1AVrbmqTsT_NYtGM9&arm=e&fexp=72519171,72519168