Oregon > Workers Comp > First Report Of Injury
Report Of Injury Or Illness 801 - Oregon
| Report Of Injury Or Illness Form. This is a Oregon form and can be used in First Report Of Injury Workers Comp . |
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Insert insurer name, address, and phone number 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 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. a.m. Date of Date you Time you began work Regularly scheduled p.m. days off: injury or illness: left work: on day of injury: Time of injury a.m. Time you a.m. Check here if you are employed by or illness: M T WT F S S p.m. more than one employer: p.m. left work: What is your illness or injury? What part of the body? Which side? (Example: sprained right foot) Left Right DEPT USE: Emp Ins Occ Nat What caused it? What were you doing? Include vehicle, machinery, or tool used. (Example: fell ten feet when climbing an extension ladder carrying a 40-lb. box of roofing materials) Part Ev Src 2src Information ABOVE this line; date of death, if death occurred; and OR-OSHA case log number must be released to an authorized worker representative upon request. Your legal name: Your mailing address: SSN (optional): Names of witnesses: Name of physician or health-care professional: Were you hospitalized overnight as an inpatient? Yes No Birthdate: Home phone: Occupation: Work phone: Gender: M F If medical treatment was given away from the worksite, print name and address of facility: Were you treated in the emergency room? Yes No By my signature, I am giving notice of a claim for workers' compensation benefits. The above information is true to the best of my knowledge and belief. I authorize health care providers 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 require separate authorization. Worker Completed by Date: (please print): signature: 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: If worker leasing company, list client business name: Address of principal place of business (not P.O. box): Street address from 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? Were other workers injured? Date employer knew of claim: Employer signature: Phone: FEIN: Client FEIN: Insurance policy no.: ZIP: Nature of business in which worker is/was supervised: Yes No Yes No Worker's weekly wage: $ Name and title (please print): OSHA 300 log case #: Date worker hired: If fatal, date of death: Date: Date worker returned to work: 440-801 (8/04/DCBS/WCD/WEB) OSHA requirements: On the job fatalities and catastrophes must be reported to OR-OSHA within eight hours. Report any accident that results in overnight hospitalization within 24 hours to OR-OSHA. Call (800) 922-2689, (503) 378-3272, or Oregon Emergency Response (800) 452-0311, on nights and weekends. 801 American LegalNet, Inc. www.USCourtForms.com
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