Insert self-insured employer and insurer name, address, phone number, and service company, if any




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Insert self-insured employer and insurer name, address, phone number, and service company, if any.

     

Report of Job Injury or Illness

Workers’ compensation claim






Worker

To make a claim for a work-related injury or illness, fill out the worker portion of this form and give it to your employer. If you do not intend to file a workers’ compensation claim with the insurance company, do not sign the signature line. Your employer will give you a copy.






Date of

injury or illness:      



Date you

left work:      



Time you began work

on day of injury:      



 a.m.

 p.m.

Regularly scheduled days off:



M T W T F S S



Dept Use:




Emp




Time of injury

or illness:      



 a.m.

 p.m.

Time you

left work:      



 a.m.

 p.m.

Check here if you have more than one job: 




Ins




What is your illness or injury? What part of the body? Which side? (Example: Sprained right foot) Left Right

     

Occ




Nat




What caused it? What were you doing? Include vehicle, machinery, or tool used. (Example: Fell 10 feet when climbing an extension ladder carrying a 40-pound box of roofing materials)      

Part




Ev




Src




2src




Information ABOVE this line; date of death, if death occurred; and Oregon OSHA case log number must be released to an authorized worker representative upon request.




Your legal name:      

Language preference:      

Birthdate:      

Gender: M  F 




Your mailing address:      

Home phone:      




Social Security no. (see Form 3283):      

Occupation:      

Work phone:      




Names of witnesses:      




Name and phone number of health insurance company:

     

Name and address of health care provider who treated you for the injury or illness you are now reporting:

     




Were you hospitalized overnight?  Yes  No




Were you treated in the emergency room?  Yes  No




By my signature, I am making a claim for workers’ compensation benefits. The above information is true to the best of my knowledge and belief. I authorize health care providers and other custodians of claim records to release relevant medical records to the workers’ compensation insurer, self-insured employer, claim administrator, and the Oregon Department of Consumer and Business Services. Notice: Relevant medical records include records of prior treatment for the same conditions or of injuries to the same area of the body. A HIPAA authorization is not required (45 CFR 164.512(I)). Release of HIV/AIDS records, certain drug and alcohol treatment records, and other records protected by state and federal law requires separate authorization.
















Worker

signature:



Completed by

(please print):      


Date:      












Employer

Complete the rest of this form and give a copy of the form to the worker. Notify your workers’ compensation insurance company within five days of knowledge of the claim. Even if the worker does not wish to file a claim, maintain a copy of this form.






Employer legal

business name:      



Phone:      

FEIN:      




If worker leasing company,

list client business name:      



Client

FEIN:      






Address of principal place

of business (not P.O. Box):      



Insurance

policy no.:      






Street address from which

worker is/was supervised:      



ZIP:      

Nature of business in which worker is/was supervised:

     




Address where

event occurred:      






Was injury caused by failure of a machine or product, or by a person other than the injured worker?  Yes  No




Were other workers injured?  Yes  No

OSHA 300 log case no:      




Date employer

knew of claim:      



Date worker

returned to work:      



Worker’s

weekly wage: $     



Date worker

hired:      



If fatal, date

of death:      






Employer

signature:



Name and title

(please print):      



Date:      

440-801 (01/16/DCBS/WCD/WEB)

OSHA requirements: Employers must report work-related fatalities and catastrophes to Oregon OSHA either in person or by telephone within eight hours. In addition, employers must report any in-patient hospitalization, loss of an eye, and any amputation or avulsion that results in bone or cartilage loss to Oregon OSHA within 24 hours. See OAR 437-001-0704. Call 800-922-2689 (toll-free), 503-378-3272, or Oregon Emergency Response, 800-452-0311 (toll-free), on nights and weekends.

801


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