Employer's Supplementary Report of Accident or Occupational IllnessU.S. Department of Labor Employment Standards Administration Office of Workers' Compensation ProgramsNotice: This Report must be filed promptly with the District Director in every case in which (1) Form LS-202 does not show date injured employee returned to work, and (2) each time injured employee has returned to work and later becomes disabled for work (33 U.S.C.930(b)). If the employee was disabled for work more than 3 days, compensation payments should be reported on Forms LS-206 and LS-208. Medical reports must be sent to the District Director promptly following first treatment and thereafter while treatment continues. Please type or print all information. (If additional space is needed, use back of form.) The information will be used to determine entitlement to benefits. Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number.OMB No. 1215-0031 For Office Use 1. OWCP No.2. Carrier's No.3. Name of injured employee (First, middle initial, last)4. Date of accident (Mo., day, yr.)5. Address of injured employee (Number and Street, City, State, ZIP code) 6. Name and address of your insurance carrier7. Initial Period of Disability (Use Inclusive Dates for a and b) a. From (Month, day, year)b. To (Month, day, year)c. Date returned to work (Month, day, year)8. If this report covers a period of disability after the date shown in item 7c. state each subsequent period of disability. Use inclusivedates for a. and b.a. From (Month, day, year)b. To (Month, day, year)c. Date returned to work (Month, day, year)9. Did employee receive medical attention?a.Yes -Give dates, names and addresses of doctors and hospitals providing treatment.No -Explainb.10. Was employee treated by his or her choice of physician?11. Was form LS-1 given to employee when injury was reported to you?YesNoNoYes12. Name of employer (Firm Name)13. Employer's address (Number and Street, City, State, ZIP code)14. Signature of person authorized to sign16. Date of report15. Official title of person signing(Month, day, year) for employerPublic Burden StatementWe estimate that it will take an average of 15 minutes to complete this collection of information, including time for reviewing instructions, searchingexistingdatasources,gatheringandmaintainingthedataneeded,andcompletingandreviewingthecollectionofinformation.If youhaveanycommentsregardingtheseestimatesoranyotheraspectofthiscollectionofinformation,includingsuggestionsforreducing thisburden,sendthemtotheU.S.DepartmentofLabor,DivisionofLongshoreandHaborWorker'sCompensation,200ConstitutionAvenue, N.W., Washington, D.C. 20210. DO NOT SEND THE COMPLETED FORM TO THIS OFFICERev. Oct. 19982002 © American LegalNet, Inc.
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