First Report Of Occupational Injury Or Disease Form - Delaware Department Of Labor printable pdf download

First Report Of Occupational Injury Or Disease Form - Delaware Department Of Labor

ALL COPIES OF FIRST REPORT MUST BE TYPED OR PRINTED

STATE OF DELAWARE

Department of Labor

FIRST REPORT

Office of Workers’ Compensation

P..O. Box 9954

OCCUPATIONAL INJURY

Wilmington, DE 19809-9954

Telephone 302-761-8200

OR DISEASE

CASE OR FILE NO.

EMPLOYER’S UC REPORTING NUMBER

2. EMPLOYEE SOCIAL SECURITY NO.

1.. EMPLOYEE:

FIRST

MIDDLE

LAST

3. ADDRESS – INCLUDE COUNTY AND ZIP CODE

EMPLOYEE TELEPHONE NUMBER (INCLUDE AREA CODE)

MALE

FEMALE

8. WAGE

9. WEEKLY HOURS WORKED

6. . DATE OF BIRTH

7. AGE

11. DEPARTMENT OF DIVISION REGULARLY EMPLOYED

12. HOW LONG EMPLOYED

10. OCCUPATION (REGULAR)

13.. EMPLOYER

14. PERSON MAKING OUT THIS REPORT

15. ADDRESS – INCLUDE COUNTY AND ZIP CODE

16. EMPLOYER TELEPHONE NUMBER (INCLUDE AREA CODE)

17. MAILING ADDRESS – IF DIFFERENT THAN ABOVE

18. NATURE OF BUSINESS – TYPE OF MFG., TRADE, CONSTRUCTION, SERVICE, ETC.

19. DATE OF REPORT

20. DATE OF INJURY AND TIME

21. NORMAL STARTING TIME

22. IF EMPLOYEE BACK TO WORK

23. AT SAME WAGE

GIVE DATE

YES

PM,

24. IF FATAL INJURY, GIVE DATE OF

25. DATE EMPLOYER KNEW OF INJURY

26. DATE DISABILITY BEGAN

27. LAST FULL DAY PAID – DATE

DEATH.

28. DESCRIBE THE INJURY/ILLNESS AND PART OF BODY AFFECTED.

29. SPECIFY THE DEPARTMENT WHERE INCIDENT OCCURRED AND THE WORK PROCESS INVOLVED.

30.. LIST THE EQUIPMENT, MATERIALS, AND CHEMICALS EMPLOYEE WAS USING WHEN THE INCIDENT OCCURRED, E.G. ACETYLENE.

31. DESCRIBE THE EMPLOYEE’S ACTIVITY AT THE TIME OF INJURY OR ILLNESS, I.E.

32. DESCRIBE HOW THE INJURY/ILLNESS OCCURRED

33. NAME OF PHYSICIAN

34. PHYSICIAN’S ADDRESS

35. HOSPITAL (IF APPLICABLE)

36. HOSPITAL ADDRESS

(THIS SECTION MUST BE COMPLETED IN ORDER TO PROCESS)

37. WORKERS’ COMPENSATION INSURANCE COMPANY NAME, COMPLETE ADDRESS AND TPA (if applicable)

I.A.B. CODE

_________

DISTRIBUTION OF THIS REPORT (1 original and 3 copies)

ORIGINAL MUST BE SENT IMMEDIATELY TO WORKER’S COMPENSATION INSURANCE CARRIER.

COPY TO INDUSTRIAL ACCIDENT BOARD

EMPLOYER’S COPY – RETAIN AS RECORD

EMPLOYEE’S COPY

____________________________________________________________________________

___________________________________________________

SIGNATURE OF PERSON IN 14 ABOVE

OFFICIAL POSITION

DOC. NO. #60-07-01-90-10-04

First Report Of Occupational Injury Or Disease Form - Delaware Department Of Labor

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