Fillable FORM 101: EMPLOYERS FIRST REPORT OF INJURY OR (Town of Oak Bluffs)

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FORM 101: EMPLOYERS FIRST REPORT OF INJURY OR (Town of Oak Bluffs)

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The Commonwealth of Massachusetts
Department of Industrial Accidents – Department 101
1 Congress Street, Suite 100, Boston, Massachusetts 02114-2017
Info. Line 800-323-3249 ext. 470 in Mass. Outside Mass. - 617-727-4900 ext. 470
http://www.mass.gov/dia
EMPLOYER’S FIRST REPORT OF INJURY
OR FATALITY
THIS FORM MUST BE FILED BY THE EMPLOYER IN THE EVENT OF AN INJURY THAT RESULTS IN DEATH
OR FIVE OR MORE CALENDAR DAYS OF TOTAL OR PARTIAL INCAPACITY FROM EARNING WAGES.
INSTRUCTIONS AND CODES ON THE REVERSE SIDE - Please Print Legibly or Type - Unreadable forms will be returned.
DIA USE ONLY
FORM 101
Form 101 - Revised 7/2010 - Reproduce as needed.
THIS FORM DOES NOT CONSTITUTE AN EMPLOYEE’S CLAIM FOR BENEFITS UNDER WORKERS’ COMPENSATION.
1. Employee’s Name (Last, First, MI): 2. Home Telephone Number:
5. Home Address (No., Street, City, State & Zip Code): 5a. Native Language Code:
8. Date of Hire (mm/dd/yyyy):
11. Employer’s Name: 12. Federal Tax I.D. Number:
13. Employer’s Address (No., Street, City, State & Zip Code):
16. Workers’ Compensation Insurance Carrier and Tel. No.
(NOT LOCAL AGENT/ADMINISTRATOR):
14. Employer’s Telephone Number:
20. DATE OF INJURY (mm/dd/yyyy):
21. Was Employee Injured on Employer’s Premises? Yes No
23. FIRST day of Total or Partial Incapacity to Earn Wages
(mm/dd/yyyy):
27. Briefly Describe How Injury/Exposure Occurred and Body Part(s) involved:
28. Person to Whom Injury was Reported (list position):
E
M
P
L
O
Y
E
E
3. Social Security Number*:
4. Sex:
M F
6. Marital Status:
M S
7. No. of Dependents:
9. Date of Birth (mm/dd/yyyy): 10. Average Weekly Wage:
Estimated Actual
$
E
M
P
L
O
Y
E
R
15. Industry Code (See Reverse Side):
17. W.C. Policy Number:
18. Self-Insured? Yes No
If Yes, Self-Insurer Number:
19. Business Type :
Service Wholesale Mfg.
Retail Other ________________________
I
N
J
U
R
Y
I
N
F
O
R
M
A
T
I
O
N
22. Location of Injury if not on Employer’s Premises:
25. If Employee has Died, Date of Death (mm/dd/yyyy):
24. FIFTH day of Total or Partial Incapacity to Earn Wages
(mm/dd/yyyy):
29. Date Reported (mm/dd/yyyy): 30. Date Reported as work related
(mm/dd/yyyy):
31. Injury Code(s)
a. to body part
b. to body part
c. to body part
Body Part Code(s)
a.
b.
c.
32. Witness(es) to Injury - Give Full Name(s), if none state as such:
33. Has Employee Returned to Work? Yes No
34. Date Employee Returned to Work(mm/dd/yyyy):
35. Employee’s Regular Occupation:
36. Has Employee Returned to Regular Occupation: Yes No
37. PREPARER’S Name (SEE INSTRUCTIONS ON REVERSE SIDE): 38. PREPARER’S Title:
39
. PREPARER’S Signature (SEE INSTRUCTIONS ON REVERSE SIDE): 40. Date Prepared (mm/dd/yyyy):
26. Source of Injury (Chemicals, Machinery, etc.):
*Disclosure of Social Security Number is Voluntary. It will aid in the processing of your report.
Other:________________
40a. PREPARER’S e-mail address:
20a. Insurer’s Case/Claim File No.:
P
R
E
P
A
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Print Form
EMPLOYER’S FIRST REPORT OF INJURY OR FATALITY
FILING INSTRUCTIONS
1. WHEN TO FILE: File this form within 7 calendar days, not including Sundays and legal holidays, of receipt of notice of any injury alleged to have arisen
out of and in the course of employment, which totally or partially incapacitates an employee for a period of 5 or more calendar days from earning wages.
This form is not an admission of liability, but must be filed even though the Employer may believe that the Employee is not injured, or that the Employee is
not entitled to benefits under M.G.L. Chapter 152.
2. WHERE TO FILE: This form should be mailed to the Department of Industrial Accidents at the address shown on the front of the form. Copies must also be
provided to the Employee and to the Employer’s Workers’ Compensation insurer.
3. PENALTIES: Failure to report injuries on this form may result in a fine of $100.00 in accordance with M.G.L. Chapter 152, Section 6.
4. EMPLOYER’S NAME & SIGNATURE IN BOXES 37 & 39: This form must be filed by the employer or an authorized agent/representative of the
employer.
NATURE OF INJURY OR ILLNESS CODES
Agriculture, Forestry and Fishing
01 Agriculture Production - Crops
02 Agriculture Production - Livestock
07 Agricultural Services
08 Forestry
09 Fishing, Hunting and Trapping
Mining
10 Metal Mining
12 Coal Mining
13 Oil and Natural Gas
14 Nonmetallic Minerals, Except Fuels
Construction
15 General Building Contractors
16 Heavy Construction, Ex. Building
17 Special Trade Contractors
Manufacturing
20 Food and Kindred Products
21 Tobacco Products
22 Textile Mill Products
23 Apparel and Other Textile Products
24 Lumber and Wood Products
25 Furniture and Fixtures
26 Paper and Allied Products
27 Printing and Publishing
28 Chemicals and Allied Products
29 Petroleum and Coal Products
30 Rubber and Misc. Plastic Products
31 Leather and Leather Products
32 Stone, Clay and Glass Products
33 Primary Metal Industries
34 Fabricated Metal Products
35 Industrial Machinery and Equipment
36 Electronic and Other Electrical Equipment
37 Transportation Equipment
38 Instruments and Related Products
39 Miscellaneous Manufacturing Industries
Transportation and Public Utilities
40 Railroad Transportation
41 Local and Interurban Passenger Transit
42 Trucking and Warehousing
43 U.S. Postal Service
44 Water Transportation
45 Transportation by Air
46 Pipelines, Except Natural Gas
47 Transportation Services
48 Communications
49 Electric, Gas and Sanitary Services
Wholesale Trade
50 Wholesale Trade - Durable Goods
51 Wholesale Trade - Non-durable Goods
Retail Trade
52 Building Materials and Garden Supplies
53 General Merchandizing
54 Food Stores
55 Automotive Dealers and Service Stations
56 Apparel and Accessory Stores
57 Furniture and Home Furnishing Stores
58 Eating and Drinking Establishments
59 Miscellaneous Retail
Finance, Insurance and Real Estate
60 Depository Institutions
61 Non-depository Institutions
62 Security and Commodity Brokers
63 Insurance Carriers
64 Insurance Agents, Brokers and Service
65 Real Estate
67 Holding and Other Investment Officers
Services
70 Hotels and Other Lodging Places
72 Personal Services
73 Business Services
75 Auto Repair Services and Parking
76 Miscellaneous Repair Services
78 Motion Pictures
79 Amusements and Recreation Services
80 Health Services
81 Legal Services
82 Educational Services
83 Social Services
84 Museums, Botanical, Zoological Gardens
86 Membership Organizations
87 Engineering and Management Services
88 Private Households
89 Services, NEC
Public Administration
91 Executive, Legislative and Garden
92 Justice, Public Order, and Safety
93 Finance, Taxation, and Monetary Benefits
94 Administration of Human Services
95 Environmental Quality and Housing
96 Administration of Economic Program
97 National Security and International Affairs
Non-classifiable Establishments
99 Non-classifiable Establishments
INDUSTRY CODES
*UNS - UNSPECIFIED **NEC - NOT ELSEWHERE CLASSIFIED
100 Amputation or Enucleation
110 Asphyxia or Strangulation Etc.
120 Burns (Heat)
130 Burns (Chemical)
140 Concussion
160 Contusion, Crushing, Bruise
170 Cut, Laceration, Puncture
190 Dislocation
200 Electric Shock, Electrocution
210 Fracture
250 Hernia, Rupture
300 Scratches, Abrasions
310 Sprains, Strains
400 Multiple Injuries
900 No Injury
950 Damage to Prosthetic Devices
995 No Other Injury, NEC**
999 Non-classifiable
Infective or Parasitic Disease
150 Infective or Parasitic Disease, UNS*
151 Amebiasis
152 Anthrax
153 Brucellosis
154 Conjunctivitis and Opthalmia
156 Tetanus
BODY PART AFFECTED CODES
157 Tuberculosis
159 Other Infective or Parasitic Diseases
Dermatitis
180 Dermatitis, UNS*
183 Primary Infections of the Skin
184 Other Skin Conditions
185 Dermatitis, Allergenic or Contact
189 Skin Condition, NEC**
Poisoning Systemic
270 Poisoning, Systemic, UNS*
271 Due to Toxic Materials other than Lead
272 Diseases of the Blood and Blood Forming
Organs
273 Upper Respiratory Conditions
274 Influenza, Pneumonia, Etc.
276 Other Diseases of the Gastro-Intestinal
Tract
278 Effects of Lead
279 Other Toxic Effects of One System Only
Respiratory Systems, Conditions of
570 Respiratory Systems, Conditions of
571 Upper Respiratory
572 Asthma, Influenza, Pneumonia
Pneumoconiosis
280 Pneumoconiosis
281 Aluminosis
282 Anthracosis
283 Asbestosis
284 Byssinosis
285 Siderosis
286 Silicosis
287 Other Pneumoconioses
289 Pneumoconiosis and Tuberculosis
Nervous System, Conditions of
560 Nervous System, Conditions of - NEC**
561 Diseases of the Central Nervous
System
562 Diseases of the Nerves and Peripheral
Ganglia
Neoplasm Tumor
550 Neoplasm Tumor, UNS*
551 Malignant
552 Benign
Radiation Effects
290 Radiation Effects, UNS*
291 Non-Ionizing Radiation
292 Microwaves
293 Ionizing Radiation - X-Ray
294 Ionizing Radiation - Isotopes
295 Welder’s Flash
Other
265 Carpal Tunnel Syndrome
510 Cardiovascular and Other Conditions
of the Circulatory System
520 Complications Peculiar to Medical Care
500 Effects of Changes in Atmospheric
Pressure
240 Effects of Environmental Heat
220 Effects of Exposure to Low Temperature
530 Eye, other Diseases of the Eye
230 Hearing Loss or Impairment
991 Heart Condition ,Excludes Heart Attack
320 Hemorrhoids
330 Hepatitis, Serum and Infective
275 Hepatitis, Toxic
260 Inflammation of Joints, Etc.
540 Mental Disorders
900 No Illness
999 Non-classifiable
990 Occupational Disease, NEC**
580 Symptoms and Ill-defined Conditions
Head
100 Head, UNS*
110 Brain
120 Ear(s), UNS*
121 Ear(s), External
124 Ear(s), Internal
130 Eye(s), UNS*
140 Face, UNS*
141 Jaw, Chin
144 Mouth and Throat (vocal chords, larynx)
146 Nose
148 Face, Multiple Parts
149 Face, NEC**
150 Scalp
160 Skull
198 Head Multiple
200 Neck & Cervical Vertebrae
UPPER EXTREMITIES
300 Upper Extremities, NEC**
310 Arm(s), UNS*
311 Upper Arm
313 Elbow(s)
315 Forearm(s)
318 Arm(s), Multiple
319 Arm(s), NEC**
320 Wrist(s)
330 Hand(s), Not Wrists or Fingers
340 Finger(s)
398 Upper Extremities, Multiple
400 Trunk, UNS*
410 Abdomen, Internal Organs,
Inguinal Hernia
420 Back
430 Chest, Ribs, Breastbone,
Internal Organs
440 Hip(s)..,Pelvis, Organs and
Buttocks
450 Shoulder(s)
498 Trunk, Multiple
LOWER EXTREMITIES
500 Lower Extremities
510 Leg(s), UNS*
513 Knee(s)
515 Lower Leg(s)
518 Leg(s), Multiple
519 Leg(s), NEC**
520 Ankle(s)
530 Foot or Feet, Not Ankle
540 Toe(s)
598 Lower Extremities, Multiple
700 MULTIPLE PARTS
Applies when more than one major body part
as been effected such as an arm and a leg
999 NON-CLASSIFIABLE - Insufficient infor-
mation to identify part of body effected. In-
cludes damage to prosthetic devises.
NATIVE LANGUAGE CODES
1 – English / 2 – Portuguese / 3 – Haitian Creole / 4 – Spanish / 5 – Chinese / 6 – Vietnamese / 7 – Cape Verdean / 9 – Other
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FORM 101: EMPLOYERS FIRST REPORT OF INJURY OR (Town of Oak Bluffs)

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Completed 17 January 2021

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