California law requires employers to report within five days of knowledge every occupational injury or illness which results in lost time beyond the date of the incident OR requires medical treatment beyond first aid.

• Provide the employee with Workers’ Compensation Claim Form (DWC 1) & Notice of Potential Eligibility form (e3301) within one working day of notice that a work-related injury or illness may have occurred; • Complete an Employer’s Report of …

This report is required by 33 U.S.C. 930(a) and must be filed with the U.S. Department of Labor, Office of Workers' Compensation Programs, Division of Federal Employees', Longshore and Harbor Workers' Compensation by electronic submission via OWCP web portal, facsimile or Central Mail Receipt Site.

Forms are grouped by relevant subject, then in alphabetical order. Use the arrows to change to reverse alphabetical order or search by form number. The ten most-downloaded forms also appear in the “ Frequently used forms ” section. Fillable form instructions = Fillable Adobe Acrobat form - en español = Adobe Acrobat for = Word form. Back to top.

All employers, including those partially exempted by reason of company size or industry classification, must report to OSHA any workplace incident that results in a fatality, in-patient hospitalization, amputation, or loss of an eye.

2019年9月19日 · Included on this page, you will find an employee incident/accident report form, a supervisor's incident investigation report template, a statement of witness to accident template, an employee's return to work plan, and many more helpful workplace accident report forms.

Forms for Injured Workers. Below is a listing of some of the most important forms for injured workers. To view all of our forms, use our form search. On This Page. Filing a Claim; Mandated Forms; Informational; Getting Treatment; Claim Forms Filing a Claim. Employer's Report of Occupational Injury or Illness – CDCR

Use this sample form to document an accident or near miss incident involving an employee.

If you do not anticipate that medical treatment will be needed, you should complete an incident report as a company record. This verifies that the worker has met the requirement for promptly notifying you that an accident occurred. Download a copy of the incident report form (S-767) here.

Applicable in Arizona: For your protection Arizona law requires the following statement to appear on this form. Any person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties.