Non Covered Employers Report Of Occupational Injury Or Illness (Supplement)
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Non Covered Employers Report Of Occupational Injury Or Illness (Supplement) Form. This is a Texas form and can be use in Employer Workers Compensation.
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Tags: Non Covered Employers Report Of Occupational Injury Or Illness (Supplement), DWC-7 Supp, Texas Workers Compensation, Employer
EMPLOYER DATA
1.Employer's Business Name
2. Federal Employer ID No.
REPORT FOR MONTH OF:
YEAR: ________
INJURY DATA
3
10. Date of Injury/Illness
(m-d-y)
Employee’s Name
Last
15. Social Security Number
First
16. Sex
MI
17. DOB (m-d-y)
M
11. Employee 6 Digit
NAICS code
12. Equipment
13. Nature of INJ/ILL
22. Description of Incident
14. Body Part(s) Affected
23. Lost Time
>1 Day - 7 Days
F
8 Days or More
18. Race/Ethnic Identification
White (not of Hispanic origin)
Hispanic
Black (not of Hispanic origin)
19. Cause of Injury
20. Location of Injury (see instructions)
26.
Last
DWC USE ONLY
YES
SRCE
12. Equipment
ACCDT
AOS
13. Nature of INJ/ILL
17. DOB (m-d-y)
22. Description of Incident
23. Lost Time
F
>1 Day - 7 Days
18. Race/Ethnic Identification
Hispanic
Black (not of Hispanic origin)
19. Cause of Injury
8 Days or More
24. Occupational Disease
YES
NO
Asian or Pacific Islander
American Indian or Alaskan Native
20. Location of Injury (see instructions)
A
B
21. Employee's Occupation
26.
DWC USE ONLY
C
YES
First
16. Sex
MI
17. DOB (m-d-y)
M
NAT
BOD
11. Employee 6 Digit
NAICS code
SRCE
12. Equipment
ACCDT
AOS
13. Nature of INJ/ILL
22. Description of Incident
14. Body Part(s) Affected
23. Lost Time
>1 Day - 7 Days
F
8 Days or More
18. Race/Ethnic Identification
White (not of Hispanic origin)
Black (not of Hispanic origin)
19. Cause of Injury
NO
Date (m-d-y)
10. Date of Injury/Illness
(m-d-y)
Employee’s Name
Last
15. Social Security Number
25. Fatality
21a. Hourly Wage
OCC
5
14. Body Part(s) Affected
MI
16. Sex
M
White (not of Hispanic origin)
NO
Date (m-d-y)
OCC
NAT
BOD
10. Date of Injury/Illness
11. Employee 6 Digit
(m-d-y)
NAICS code
First
NO
25. Fatality
C
21a. Hourly Wage
Employee’s Name
15. Social Security Number
YES
American Indian or Alaskan Native
A
B
21. Employee's Occupation
4
24. Occupational Disease
Asian or Pacific Islander
Hispanic
24. Occupational Disease
Asian or Pacific Islander
YES
American Indian or Alaskan Native
20. Location of Injury (see instructions)
A
B
21. Employee's Occupation
26.
DWC USE ONLY
NO
25. Fatality
C
21a. Hourly Wage
YES
NO
Date (m-d-y)
OCC
NAT
BOD
SRCE
ACCDT
AOS
date stamp
DWC FORM -7 SUP (Rev. 10/05) Page 1
DIVISION OF WORKERS’ COMPENSATION
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