ࡱ> O lbjbj"U"U 7@?e@?e44y y y y y  8 ! VS|u"o&o&o&o&*:-D_.iRkRkRkRkRkRkR$UX"Ry /*"*//Ry y o&o&PSY4Y4Y4/Fy o&y o&iRY4/iRY4Y4KO o&0nI/^OJUR&S0VSOOJY/YOYy O//Y4/////RRQ2///VS////Y/////////4 ?: Insert self-insured employer and insurer name, address, phone number, and service company, if any.  FORMTEXT      Report of Job Injury or Illness Workers compensation claimWorker 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:  FORMTEXT      Date you left work:  FORMTEXT      Time you began work on day of injury:  FORMTEXT       FORMCHECKBOX  a.m.  FORMCHECKBOX  p.m.Regularly scheduled days off:  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  M T W T F S SDept Use: EmpTime of injury or illness:  FORMTEXT        FORMCHECKBOX  a.m.  FORMCHECKBOX  p.m.Time you left work:  FORMTEXT        FORMCHECKBOX  a.m.  FORMCHECKBOX  p.m.Check here if you have more than one job:  FORMCHECKBOX InsWhat is your illness or injury? What part of the body? Which side? (Example: Sprained right foot)  FORMCHECKBOX  Left  FORMCHECKBOX  Right  FORMTEXT      OccNatWhat 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)  FORMTEXT      PartEvSrc2srcInformation 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:  FORMTEXT      Language preference:  FORMTEXT      Birthdate:  FORMTEXT      Gender: M  FORMCHECKBOX  F  FORMCHECKBOX Your mailing address:  FORMTEXT      Home phone:  FORMTEXT      Work phone:  FORMTEXT      Occupation:  FORMTEXT       Names of witnesses:  FORMTEXT      Name and phone number of health insurance company:  FORMTEXT      Name and address of health care provider who treated you for the injury or illness you are now reporting:  FORMTEXT      Were you hospitalized overnight?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Were you treated in the emergency room?  FORMCHECKBOX  Yes  FORMCHECKBOX  NoBy 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. 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Worker signature: Completed by (please print):  FORMTEXT       Date:  FORMTEXT      Employer Complete the rest of this form and give a copy of the form to the worker. Even if the worker does not want to file a claim, keep a copy of this form.Employer legal business name:  FORMTEXT      Phone:  FORMTEXT      FEIN:  FORMTEXT      If worker leasing company, list client business name:  FORMTEXT      Client FEIN:  FORMTEXT      Address of principal place of business (not P.O. Box):  FORMTEXT      Insurance policy no.:  FORMTEXT      Street address from which worker is/was supervised:  FORMTEXT      ZIP:  FORMTEXT      Nature of business in which worker is/was supervised:  FORMTEXT      Address where event occurred:  FORMTEXT      Was injury caused by failure of a machine or product, or by a person other than the injured worker?  FORMCHECKBOX  Yes  FORMCHECKBOX  NoWere other workers injured?  FORMCHECKBOX  Yes  FORMCHECKBOX  NoOSHA 300 log case no:  FORMTEXT      Date employer knew of claim:  FORMTEXT      Date worker returned to work:  FORMTEXT      Worker s weekly wage: $ FORMTEXT      Date worker hired:  FORMTEXT      If fatal, date of death:  FORMTEXT      By my signature, I acknowledge I am responsible for notifying my workers compensation insurance company within five days of knowledge of the claim. I understand I may not restrict the worker s choice of or access to a health care provider. If I do, it could result in civil penalties under ORS 656.260.Employer signature:Name and title (please print):  FORMTEXT      Date:  FORMTEXT      440-801 (1/21/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. 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