U.S. Department of Labor
Office of Workers' Compensation Programs
Employer's Supplementary Report of
Accident or Occupational Illness
Notice: This Report should be filed promptly with the District Director in every case in which (1)
Form LS-202 does not show date injured employee returned to work, and (2) each time injured
employee has returned to work and later becomes disabled for work (33 U.S.C.930(b) if the information
3 days, compensation payments should be reported on Forms LS-206 and LS-208. Medical reports
must be sent to the District Director promptly following first treatment and thereafter while treatment
continues. Please type or print all information. (if additional space is needed, use back of form.)
The information will be used to determine entitlement to benefits.
OMB No. 1240-0003
For Office Use
1. OWCP No.
2. Carrier's No.
4. Date of accident (Month, day, year)
3. Name of injured employee (First, middle initial, last)
6. Name and address of your insurance carrier
5. Address of injured employee (Number and Street, City, State, ZIP code)
7. Initial Period of Disability
(Use Inclusive Dates for a and b)
b. Through (Month, day, year)
c. Date returned to work (Month, day, year)
a. From (Month, day, year)
8. If this report covers a period of disability after the date shown in item 7c. state each subsequent period of disability. Use inclusive dates for
a. and b.
a. From (Month, day, year)
b. Through (Month, day, year)
c. Date returned to work (Month, day, year)
9. Did employee receive medical attention?
No - ExplainYes - Give dates, names and addresses of doctors and hospitals providing treatment.
b.
a.
10. Was employee treated by his or her choice of physician?
NoYes
11. Was form LS-1 given to employee when injury was reported to you?
Yes
No
12. Name of employer (Firm Name)
13. Employer's address (Number and Street, City, State, ZIP code)
16. Date of report
15. Name, official title and phone number of person signing
14. Signature of person authorized to sign
for employer
(month, day, year)
Public Burden Statement
valid OMB control number. Public reporting burden for this collection of information is estimated to average 15 minutes per response, including time for
reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of
information. Use of this form is optional, however furnishing the information is required in order to obtain and/or retain benefits. (33 U.S.C. 930(b)). Send
comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the
DO NOT SEND THE COMPLETED FORM TO THIS OFFICE.
Form LS-210
Rev. March 2014
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a
U.S. Department of Labor, 200 Constitution Avenue, NW, Room C-4319, Washington, D.C. 20210, and reference the OMB Control Number.
is not already reported via Form LS-206 or LS-208. If the employee was disabled for work more than
