Form 1 - State Of Delaware First Report Of Occupational Injury Or Disease
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6Accident Investigation and Reporting Program
Required Forms
Instructions and Guidance
This document contains multiple forms that must be completed for all employee accidents, illnesses or injuries.
The purpose of these forms is to ensure compliance with the State of Delaware Workers’ Compensation Laws,
ensure proper payment of medical bills and to provide Environmental Health and Safety (EHS) with the necessary
information to investigate the accident.
There are four separate forms that may be required:
Form #1: State of Delaware First Report of Occupational Injury or Disease.
Contact Labor Relations at 302-831-
8305 if you have questions or need assistance with this form.
• This form must be completed for all accidents, injuries and illnesses regardless of medical
treatment. The form will be used to ensure payment of medical bills or salary due to lost time.
• This form is included below.
• Send this completed form to Labor Relations
Form #2:
University of Delaware Illness/Injury Loss Investigation Report.
Contact EHS at 302-831-8475 if you
have questions or need assistance with this form.
• This form must be completed for all accidents, injuries and illnesses regardless of medical
treatment. The form is initially completed by the supervisor and sent to EHS. EHS will use the
data gathered in the form to complete an accident investigation.
• Send this completed form to Supervisor, Safety Chair, Environmental Health and Safety, Labor
Relations
• This form is included below.
Form #3:
State of Delaware Workers' Compensation Employer’s Modified Duty Availability Report.
Contact
Labor Relations at 302-831-8305 if you have questions or need assistance with this form.
• The form is completed if the employee receives medical treatment for the injury or illness.
• This form is completed by the supervisor after she/he reviews the work restrictions listed in the
Physician’s Report of Workers Compensation Injury.
The supervisor will outline how the
employee’s job functions will be changed to accommodate the treating physician’s work
restrictions. The completed form must be sent to the treating physician for approval of the work
accommodations.
• Send this completed form to Labor Relations
• This form is included below. It is also available online.
•
Form #4:
State of Delaware Workers’ Compensation Physician’s Report of Workers Compensation Injury.
Contact Labor Relations at 302-831-8305 if you have questions or need assistance with this form.
• This form must be completed by the treating physician and outlines any work restrictions required
due to the injury or illness. The physician will send the form to the employee and the employer
within 14 days of treatment. It is recommended that the supervisor send the approved job
description to the treating physician for review.
• This form is currently available online as a PDF document.
•
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