Mail this form to: STATE OFFICE OF RISK MANAGEMENT P. O. Box 13777 Austin, Texas 78711 CLAIM # Please read instruction sheet CAREFULLY, giving special attention to items marked with an asterisk (*). SORM CLAIM # EMPLOYERS FIRST REPORT OF INJURY OR ILLNESS 1. Name (Last, First, M.I.) 2. Sex M - 3. Social Security Number 4. Home Phone ( 6. Does the Employee Speak English? YES 5. Date of Birth (m-d-y) ) 17. Date Lost Time Began (m-d-y) - 16. Time of Injury 15. Date of Injury (m-d-y) F - : - 18. Nature of Injury* am pm 19. Part of Body Injured or Exposed* - If No, Specify Language 20. How and Why Accident/Injury Occurred* NO 7. Employee Telephone # 9. Mailing Address Street or P.O. Box City 22. Worksite Location of Injury (stairs, dock, etc.)* 21. Was employee doing his/her YES regular job? NO 8. Block no longer used 23. Address Where Injury or Exposure Occurred Name of business if incident occurred on a business site State Zip Code County 10. Marital Status Street or P.O. Box County City Married Widowed Separated 11. Number of Dependent Children Single 12. Spouse's Name 13. Doctor's Name Telephone # 25. List Witnesses (Name, Telephone # 26. Return to work date (m-d-y) State 30. Date of Hire (m-d-y) YES 31. Was employee hired or recruited in Texas? YES 36. Rate of Pay at this Job Weekly $______ Hourly $ $ Monthly 27. Did employee die? Zip Code Years 28. Supervisor's Name 29. Date Reported (m-d-y) NO 32. Length of Service in Current Position NO 34. State Payroll Classification Code Zip Code 24. Cause of Injury (fall, tool, machine, etc.)* 14. Doctor's Mailing Address (Street or P.O.Box) City State Divorced 33. Length of Service in Occupation Months ______ Years Months ______ 35. Occupation of Injured Worker 37. Full Work Week is: Hours 38. Last Paycheck was: Days 39. Is employee an Owner, Partner, or Corporate Officer? $_____________ YES NO 41. Name of Agency 40. Name and Title of Person Completing Form Claims Coordinator 42. Agency Mailing Address and Telephone Number Street or P.O. Box City State 44. Federal Tax Identification Number 43. Agency Location Code Telephone ( ) ______ ______ ______ / _______ ______ _______ / ______ _______ _______ Zip Code Name of Location: ____________________________________________ 45. Primary North American Industrial Classification System 46. Specific NAICS Code 47. Comptroller Agency Code Sector Code (NAICS) (2 digits) 48. Workers' Compensation Insurance Company 49. Policy Number State Office of Risk Management 50. Did you request accident prevention services in past 12 months? TXSTATEPOL001 52. Number of Hours of Sick/Annual Leave Credted to Employee or Date of Injury YES NO If yes, did you receive them? YES NO 51. Signature and Title (READ INSTRUCTIONS ON INSTRUCTION SHEET BEFORE SIGNING) American LegalNet, Inc. www.USCourtForms.com DWC FORM-1S (Rev. 10/05) Page 1 DIVISION OF WORKERS’ COMPENSATION DWC FORM-1S Instructions PLEASE COMPLETE ALL APPLICABLE FIELDS. Most fields are self-explanatory; however, the following items may require more attention: Item 4: If no home phone, please give a phone number where the employee can be reached. Item 7: Employees work phone number. Item 8: This information is no longer required. Item 13: This information should include the doctor’s telephone number. Item 15: This should be the actual date of injury, or (for occupational diseases) the date the employee knew or should have known the condition was work-related. Item 17: This should be the first full day of lost-time from work. (Please note that the date of injury is not considered the first day of lost time.) Mark NLT or N/A if there is no lost time. Item 18: List the nature of the injury. Examples include: burn, cut, or sprain. Item 19: List specific body part, which side of body is affected, e.g., chin, right leg, left upper arm, etc. If more than one body part is affected, list each part. Item 20: Describe in detail. Use additional sheet of paper if necessary. Item 24: This should state the specific substance or exposure that directly inflicted the injury such as a tool, chemical (list the name of the chemical), or machine. Item 26: The date should be entered even if the employee has returned to work even for a portion of the day. If the employee has returned to work making less than his or her pre-injury wage, a DWC FORM-6 must also be submitted. Item 28: This is the employee’s immediate supervisor. Please include a work telephone number. Item 29: This is the date the employee reported the injury to the employer as work related. Item 34: This 4-digit code corresponds to the primary occupation in which the employee was engaged at the time of the injury or exposure. This code is from the state payroll classification table and is available from the State Comptroller of Public Accounts. Item 43: This 9-digit code represents the location of the agency unit that employed the injured worker at the time of their injury or exposure. The first three digits will be 100 for state agencies or 200 for county entities. The second three digits are the agency code. The third three digits are the location code as established by each agency. Contact the SORM’s Risk Assessment and Loss Prevention section for information about or changes to your agency location code(s). Item 44: This 9-digit code is assigned to each agency by the Internal Revenue Service for employment, tax, and reporting purposes. Item 45: This 2-digit code is assigned to each agency according to its primary business activity. For specific questions regarding your NAICS code, call your local Texas Workforce Commission (TWC). Item 46: This is a 3- or 4-digit code for the specific subsector of the business activity of the agency. Item 47: This is the state agency code number assigned by the State Comptroller of Public Accounts. Item 51: This must be the signature and title of the claims coordinator. If signed by someone other than the claims coordinator, he or she must list his or her title and state that it was signed for the claims coordinator. The date must also be included. Item 52: Enter the number of sick/annual leave hours credited to the employee as of the date of injury. Distribution: Fax a copy or mail the original to: State Office of Risk Management Mail a copy to the claimant. Retain a copy for your file. State Office of Risk Management P.O. Box 13777 Austin, TX 78711-3777 American LegalNet, Inc. www.USCourtForms.com DWC FORM-1S (Rev. 10/05) Page 2 DIVISION OF WORKERS’ COMPENSATION