NOTE: This form satisfies OSHA Form 301 record-keeping requirements. Complete only this page (Page 1) if the worker is not filing a claim. If the worker completes Page 2 and files a workers’ compensation claim, attach a copy of this form and send both to your insurer within five days of notice or knowledge of a claim.
illness, including part of body affected and object or substance involved. Example: “Climbing a ladder while carrying roofing materials. Ladder slipped on wet floor and worker fell twenty feet to concrete floor and broke his shoulder.”
39. Worker’s shift on day of injury (from) a.m. p.m.
(to) a.m. p.m.
40. Date of injury or illness:
41. Time of injury or illness:
43. If fatal, date of death:
Employer’s signature Date
44. Print name, title, and phone number of signer:
Laura Hyde, Executive Assistant to the City Manager, (541) 917-7508
45. OSHA log case number:
Attention: Report fatalities or catastrophes to DCBS/OR-OSHA within eight hours of occurrence. Call toll-free in Oregon (800) 922-2689 or (503) 378-3272. Report accidents that result in overnight hospitalization with medical treatment to the DCBS/OR-OSHA local field office within 24 hours of employer notification. At night or on weekends, call Oregon Emergency Response, (800) 452-0311.
14. Name of medical provider who first treated injury/illness:
15. Name of regular doctor:
16. Occupation (job title):
17. Name, phone, and ID or group no. of personal health insurer:
18. Describe the injury or illness fully (how and where it occurred):
Witnesses (if any):
19. Has body part been injured before? (If “Yes,” explain.) Yes No
20. Check here if you have more than one employer: See attached Understanding workers’ compensation claims under “If I can’t work, will I receive payments from the insurer for lost wages?” to find out if you are eligible for additional benefits.
21. By my signature: I am giving NOTICE OF CLAIM for workers’ compensation medical or disability benefits. I certify that the above information is true to the best of my knowledge and belief. I authorize medical providers and other custodians of the claim record to release medical records relevant to the injury or disease claimed on this 801 to the workers’ compensation insurance company and the Oregon Department of Consumer and Business Services. Medical information relevant to the claim includes a history of the complaints or treatment of a condition similar to that presented in the claim or other conditions related to the same body part. This form does not authorize release of the following information:
• Participation in federally funded treatment programs for drug and alcohol abuse under Fed. Regulation 42, CFR (2).
• HIV-related information unless the claimed condition is HIV or AIDS or when such information is relevant to the claimed condition(s). I authorize the use of my SSN as described in Paragraph 2 on the attached “Notice to Worker.” (If you do not authorize the use of your SSN as described in Paragraph 2, check here .)
Worker: Sign form and give it to your employer on the day you sign it. Your employer will give you a copy.
Worker’s signature Today’s date
Employer: Provide information below, sign form, and give the worker a copy immediately. Send a copy to the insurer, along with Page 1 or other injury/illness report, within 5 days of Notice of Claim. Retain a copy for your records.