Department of Consumer and Business Services 
                                                                             Workers’ Compensation Division 
                                            
            Oregon                                                           350 Winter St. NE 
                Kate Brown, Governor                                                        PO Box 14480 
                                                                             Salem, OR 97309-0405 
                                                                                            1-800-452-0288 
                                                                                            503-947-7810 
                                                                             www.wcd.oregon.gov 
 
                                     BULLETIN NO. 101 (Rev.)    
                                     Aug. 24, 2022 
  
 TO:         Workers’ compensation insurers and self-insured employers 
  
 SUBJECT:    Forms required for processing initial claims of occupational injury or disease 
  
 This bulletin provides or describes forms that meet the requirements of Oregon Revised Statute 
 (ORS) 656.265 and Oregon Administrative Rules (OAR) 436-060-0010, 436-060-0011, and 436-
 060-0015:  
  
   • Form 801, “Report of Job Injury or Illness” 
   • Form 3283, “A Guide for Workers Recently Hurt on the Job” 
   • Form 1138, “What happens if I’m hurt on the job?” 
  
 Since the last publication of this bulletin on Dec. 17, 2020, the division updated Form 3283 to: 
  
   • Change Ombudsman for Injured Workers references to Ombuds Office for Oregon 
     Workers 
   • Update email addresses  
   • Update the division’s logo 
  
 There is no immediate need to reprint or restock Form 3283. The division encourages use of the 
 revised form when you next update your system templates or need to restock. 
  
  There are no changes to Form 801. This bulletin replaces Bulletin No. 101 dated Dec. 17, 2020. 
  
 Printing and distribution of “Report of Job Injury or Illness,” Form 801 
 A.  Insurers must provide copies of Form 801 to their insured employers. Employers must provide 
   Form 801 to injured workers (or anyone acting on the worker’s behalf) immediately upon request, 
   or upon receiving notice or knowledge of an accident that may involve a compensable injury.   
  
 B.  On all reporting forms, print the name, address, and phone number of the insurer, self-insured 
   employer, and service company, if any.  
  
   Note: Some of the information on Form 801 (and the Federal Form 301) is subject to release by the 
   employer to authorized employee representatives upon request. Information must be made available 
   in such a way that confidentiality of the injured worker is protected regardless of the form used.  
  

Bulletin 101 
Page 2 

 “A Guide for Workers Recently Hurt on the Job,” Form 3283 
Insurers must provide Form 3283 to their insured employers. The employer must provide Form 3283 to 
the worker at the time a worker files a claim for workers’ compensation benefits. An insurer may revise 
the form to include its name and phone number in the heading, at the end, or in the paragraph “What if I 
have questions about my claim?” Form 3283 may be printed on the back of Form 801.  
 
“What happens if I am hurt on the job?,” Form 1138 
The insurer must provide the pamphlet (Form 1138) to every injured worker who has a disabling injury 
or disease claim with the first time-loss check or earliest written correspondence. Distribution of Form 
1138 for a nondisabling claim is not required unless requested by the worker. The division will 
furnish Form 1138 to insurers upon request, limited to a four-month supply. Contact the division at  
503-947-7627 to request copies of the pamphlet. 
 
You can download the forms from the division’s website: 
https://wcd.oregon.gov/forms/Pages/forms.aspx. If you have questions about this bulletin, contact a 
Benefit Consultant by email, workcomp.questions@dcbs.oregon.gov, or by phone, 800-452-0288 (toll-
free).  

 Sally Coen, Administrator 
 Workers’ Compensation Division 
 
Attachments:  Form 801 (Rev. 1/21) 
              Form 3283 (Rev. 7/22) 
 
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