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:
– FORMCHECKBOX
M T W T F S S Dept Use:

Emp
Time of injury
or illness:       a.m.
p.m. Time you
left work: – FORMTEXT       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) – FORMCHECKBOX 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) – FORMTEXT       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:       Work phone:       Occupation:      
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:      
440-801 (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. Call 800-922-2689 (toll-free), 503-378-3272, or Oregon Emergency Response, 800-452-0311 (toll-free), on nights and weekends. 801

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