Insert self - insured employer and insurer name, address, phone number, and service company, if any. Report of Job Injury or Illness Workers222 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 workers222 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 t he body? Which side? (Example: S prained 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 pref erence: 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 h ealth insurance company : N ame 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 workers222 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 workers222 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 w ant to file a claim, keep a copy of this form. Employer legal business name: Ph one: FEIN: If worker leasing company, list client business name: Client FEIN: Address of principal place of business (not P.O. B ox): Insurance policy n o.: Street address from which worker is/was supervised: ZIP : Nature of business in which worker is/was supervised: Address where event occurred: Was i njury 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: Worker222s weekly wage: $ Date worker hired: If fatal, date of death: By my signature, I acknowledge I am responsible for notifying my workers222 compensation insurance company within five days of knowledge of the claim. I understand I may not restrict the worker222s choice of or access to a health care provider . If I do, it could result in civil pen alties 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 eithe r 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 w eekends. 801 American LegalNet, Inc. www.FormsWorkFlow.com