Fill and Sign the Injury Illness Workers or Form

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. I understand I have a right to see a health care provider of my choice subject to certain restrictions under ORS 656.260 and ORS 656.325. Worker signature: Completed by (please print):       Date:       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:       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:       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):       Date:       440-8 01(1/17/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