Fill and Sign the Report Job Injury Form

Insert insurer name, address, and phone number       Reporte de Lesión o Enfermedad en el Trabajo (Report of Job Injury or Illness) Reclamación de compensación para trabajadores (Workers’ compensation claim) Trabajador (Worker)Para hacer una reclamación por una lesión o enfermedad ocupacional, llene la parte del formulario para el trabajador y entregela a su empleador. Si usted no tiene la intención de hacer una reclamación de compensación para trabajadores con la aseguradora, no firme en la l í nea para su firma. Su empleador le dará una copia. (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. ) Fecha de la lesión o enfermedad (Date of injury or illness) :       Fecha que dejó el trabajo (Date you left work ) :       Hora que empezó a trabajar el d í a de la lesión (Time you began work on day of injury) :       a.m. p.m. D í as que regularmente no trabaja (Regularly scheduled days off) M T W T F S S DEPT USE: Emp Ins Hora en la que ocurri ó la lesión o enfermedad (T ime of injury or illness) :       a.m. p.m. Hora que dejó el trabajo (Time you left work) :       a.m. p.m. Marque este casillero si usted tiene más de un empleador. (Check here if you are employed by more than one employer) : Occ Nat Cu á l es su lesión o enfermedad? En qu é parte del cuerpo? Qu é lado? (Ejemplo: torcedura del pie derecho) What is your illness or injury? What part of the body? Which side? (Example: sprained right foot) Izquierdo (Left) Derecha (Right)       Part Ev Cu á l fue la causa? Qu é estaba haciendo? Incluya veh í culo, maquinaria o herramienta usada. (Ejemplo: ca í diez pies mientras sub ía una escalera de extención cargando una caja de herramientas que pesaba 40 libras) 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)       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. Su nombre legal (Your legal name):       Fecha de nacimiento (Birthdate) :       Sexo (Gender) : M F Su dirección postal (Your mailing address) :       Teléfono del domicilio (Home phone) :       Número de Seguro Social (opcional) SSN (optional) :       Ocupación (Occupation) :       Teléfono del trabajo (Work phone) :       Nombres de testigos (Names of witnesses) :       Nombre del médico o profesional del cuidado médico (Name of physician or health-care professional) :       Si le dieron tratamiento médico fuera del lugar de trabajo, anote el nombre y dirección del lugar (If medical treatment was given away from the worksite, print name and address of facility) :      Estuvo hospitalizado como paciente durante la noche? (Were you hospitalized overnight as an inpatient?) Yes No Recibi ó tratamiento en la sala de emergencia ? (Were you treated in the emergency room?) Yes No Con mi firma: Estoy dando aviso de reclamación para beneficios de compensación para trabajadores. La información arriba provista es verdadera en el mejor de mi conocimiento y creencia. Yo autorizo a proveedores médicos para liberar los expedientes médicos pertinentes a la aseguradora de compensación para trabajadores, empleador asegurado por sí mismo, administrador de reclamaciones, y el Departamento para Consumidores y Negocios de Oregon. Aviso: Expedientes m édicos pertinentes incluyen registros de tratamiento anterior por las mismas condiciones o lesiones a la misma parte del cuerpo. Una autorización de HIPPA no es requerida (45 CFR 164.512(I)). Para compartir r é cords sobre el HIV /AIDS (SIDA), récords de tratamiento de drogadicci ón o alcoholismo, y otros r é cords protegidos por la ley estatal o federal se requiere una autorización separada. ( 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.) Firma del trabajador (Worker signature): Completada por (Completed by) Por favor escriba (please print):       Fecha (Date):       Empleador (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 #:       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:       440-801S (8/04 tr 11/04/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. 801S