REPORTABLE INJURY – Any accidental injury which causes loss of one or more shifts of work or death allegedly arising out of and
in the course of employment, including any occupational disease or infection believed or alleged to have arisen naturally out of
first has knowledge of an injury or death. Under the law all medical treatment and compensation must be furnished by the employer or
currently not authorized by the Department of Labor to render medical care under the Act. Compensation payments become due and
with provisions of the law. The information will be used to determine entitlement to benefits. Persons are not required to respond to
this collection of information unless it displays a currently valid OMB control number.
are payable on the 14th day after the employer first has knowledge of the injury or death. Penalties may be charged for failure to comply
its insurance company. Treatment must be by a physician chosen by the employee, unless the physician is on a list of physicians
Programs and is required by 33 U.S.C. 930(a). File form within 10 days from the date of injury or death or from the date the employer
This report is to be filed in duplicate with the District Director in the appropriate district office of the Office of Workers’ Compensation
compensation it must also file a notice of controversion with the District Director within 14 days after it has knowledge of the
alleged injury or death.
B. Nonappropriated Fund Instrumentalities Act covers
employees of nonappropriated fund instrumentalities of the
Armed forces, e.g., post exchanges, motion picture service,
etc.
C. Outer Continental Shelf Lands Act covers employees of
private employers engaged in operations conducted on the
Outer Continental Shelf for the purpose of exploring for,
developing, removing, or transporting by pipeline the natural
resources of submerged lands.
NOTE: FILING THIS FORM DOES NOT CONSTITUTE AN ADMISSION OF LIABILITY UNDER THE COMPENSATION ACT. Any
employer, insurance carrier, or self-insured employer who knowingly and willfully fails to submit this report when
required or knowingly or willfully makes a false statement or misrepresentation in this report shall be subject to a civil
report shall not be evidence of any fact stated herein in any proceeding in respect to any such injury or death on
account of which the report is made. [33 U.S.C. 930(c)]
such employment, or as a natural or unavoidable result from an accidental injury. If the employer controverts the right to
penalty not to exceed $11,000 for each such failure, refusal, false statement, or misrepresentation. [33 U.S.C.930(e)] This
Public Burden Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection
displays a 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 is optional, however furnishing the information is required in order to obtain and/or retain
and reference the OMB Control Number.
DO NOT SEND THE COMPLETED FORM TO THIS OFFICE
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 U. S. Department of Labor, 200 Constitution Avenue, N.W., Room C-4319, Washington, D.C. 20210,
Item 6 – A. Longshore and Harbor Workers’ Compensation Act
covers employees injured while engaged in maritime
employment upon the navigable waters of the United States
(including any adjoining pier, wharf, dry dock, terminal,
building way, marine railway, or other adjoining area
customarily used by an employer in loading, unloading,
repairing, or building a vessel); - employees injured upon the
navigable waters of the United States and other described
areas who at the time of injury were engaged in maritime
employment and are not otherwise specifically excluded under
the Act (33 U.S.C. 902).
D. Defense Base Act covers any employment (1) at military,
air, and naval bases acquired by the United States from foreign
countries; (2) on lands occupied or used by the United States
for military or naval purposes outside the continental limits of
the United States; (3) upon any public work in any Territory or
possession outside the continental United States under a
contract of a contractor with the United States; (4) under a
contract entered into with the United States where such
contract is to be performed outside the continental United
States and at places not within the areas described in (1), (2),
and (3) above for the purpose of engaging in public work; (5)
under certain contracts approved and financed by the United
States under the Mutual Security Act of 1954, as amended; and
(6) in the service of American employers providing welfare or
similar services for the benefit of the Armed Forces outside the
Continental United States.
Item 24 – “Exact place where accident occurred” requires the
nearest street address, city and town. In addition -
If on a vessel,
Give place on vessel where injury happened (Deck, hold,
tweendeck, engine room, etc.) Name of vessel
If either on an adjoining pier, wharf, dry dock, terminal
building way, marine railway, or other area customarily
used in loading, unloading, repairing, or building a
vessel
Name or number of pier, dry dock, marine railway, etc.
Name of the terminal or shipyard
Nearest street address – City and State
If injury or death is reported under the Defense Base
occured.
If on the Outer Continental Shelf,
Give drilling site and block number
Area name (e.g. West Delta Area)
Federal Lease Number, State Lease Number
Distance from and name of nearest land,
name of State
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Act, give the name of the country where injury or death
