Revised 10/26/2015
WORKER’S COMPENSATION COMMISSION (WCC)
Guam Department of Labor
P.O. Box 9970 Tamuning, Guam 96931
Email Address: wcc@dol.guam.gov
Tel: (671) 300-4571/77 Fax: (671) 475-6811
EMPLOYER (PUBLIC)
WHAT TO DO IN CASE OF A WORK INJURY
1. PREPARE MEDICAL AUTHORIZATION. Form GWC-101A/B (Authorization for Medical
Examination and/or Treatment), should accompany the injured person to the clinic
when obtaining initial medical treatment unless it is an emergency situation. This
form must be FULLY COMPLETED to ensure billing is correctly routed. Issue ONLY the
initial (first) authorization. WCC will then be responsible for all subsequent
authorizations (includes prescriptions) thereafter if required.
GOVGUAM EMPLOYEES: are to be sent to the GUAM MEMORIAL HOSPITAL for the
initial medical treatment pursuant to 17 GAR Div. 2, Chap. 10, 10107(b) unless
otherwise authorized by WCC. Any referrals after this initial treatment must be
authorized by WCC.
PLEASE ADVISE EMPLOYEE TO GO DIRECTLY TO WCC AFTER CHECKING OUT OF GMH.
Please instruct the injured employee NOT to utilize his/her personal health insurance
when obtaining medical care for the work injury nor to pay any of the charges
incurred.
IMPORTANT: If employee obtains medical treatment without first requesting
from the employer or WCC, employee may not be reimbursed for any out-
of-pocket medical expenses, unless employee was refused such
authorization by employer. 22 GCA §9108
2. PROVIDE THE EMPLOYEE WITH FORM GWC-201 (Notice of Employee’s Injury/Illness
or Death) or you may use your own incident report forms.
3. COMPLETE FORM GWC-202 (Employer’s Report of Occupational Injury or Illness) and
file with our office within TEN (10) calendar days from the date of the accident or
when you first became aware of the injury. The date employer obtained knowledge of
the accident/injury will be “day one (1)”. Failure to file this report in a timely manner
may subject your company/agency to penalties amounting to $500.00 for each failure
or refusal to file such report.
4.
IMPORTANT: A copy of these reports along with any and all medical documents
received from the employee MUST be provided to WCC so as to properly facilitate the
claim.
WARNING: Misrepresentation of facts in order to obtain or evade liability of worker’s compensation benefits
shall be guilty of a misdemeanor.
WORKER'S COMPENSATION COMMISSION
Department of Labor * Government of Guam * P.O. Box 9970 Tamuning, Guam 96931
Tel: (671) 300-4571/77 Fax: (671) 475-6811
WCC File#
INSTRUCTIONS: This side of the form should be completed in full. It authorizes a physician (duly qualified physicians include surgeons,
osteopathic acupuncturists within the scope of their practice as defined by law) to examine and/or treat the employee for the injuries arising out of
such accidental occupational injury, illness, or disease covered by the Guam Worker's Compensation Law. PLEASE TYPE OR PRINT LEGIBLY.
1. Name of Authorized Physician: 2. Name of Medical Facility:
Physician on Duty at GMHA
Guam Memorial Hospital Authority
3. Physician's Address: 4. Medical Facility's Address:
Same as box 4
850 Gov Carlos Camacho Road
Tamuning, Guam 96911
5. Name of Injured Employee , DoB, & SSN: 6. Occupation: 7. Date of Injury:
8. Description of Injury:
9. YOU ARE AUTHORIZED TO PROVIDE MEDICAL SERVICES TO THE EMPLOYEE AS FOLLOWS: (Please check one)
A) If you believe the condition is related to the injury, furnish office and/or hospital treatment as necessary for the effects
of the injury.
B) If there is doubt as to whether the condition is related to the injury, you are authorized to examine the employee, using
indicated non-surgical diagnostic studies, and should promptly advise those listed in Item 14 whether you believe the
disability is due to the alleged injury. Pending further advice, you may provide such necessary conservative treatment.
xxxxxxxxxxxxxx
C) Other: EXAMINATION & TREATMENT of INJURY(IES) AS STATED IN BOX 8 – SINGLE VISIT ONLY.
****** AUTHORIZATION INVALID IF ALTERED WITHOUT PRIOR APPROVAL BY WCC OFFICE ***********************
YOU ARE REQUESTED TO SUBMIT A WRITTEN REPORT OF FIRST TREATMENT WITHIN 20 DAYS TO THE COMMISSIONER AT THE ADDRESS
INDICATED ITEM 13 BELOW. (See back of this form for instructions as to the medical report and the submission of your charges). Reports are
requisite if services are to be paid.
22 GCA §9132 “Any person who willfully makes any false or misleading statement or representation for the purpose of obtaining any benefit or
payment under this Title, or for the purpose of evading liability for any benefit or payment under this Title, shall be guilty of a misdemeanor.”
10. Signature and Title of Authorizing Official: 11. Name and Address of Employer:
12. Date:
13. Send your REPORT to:
14. Name & address of Insurance Carrier to whom COPY of your report and BILL are to be sent:
WORKER'S COMPENSATION COMMISSION
P.O. Box 9970
Tamuning, Guam 96931
See Box 13
FOR STATISTICAL PURPOSES ONLY:
Employee’s ethnicity (please choose one): Employee’s citizenship (please choose one):
Yapese Pohnpeian American
Korean
Chuukese Marshalls Pacific Islander
Chinese
Kosraean Palauan Filipino
Japanese
Other (specify):
U.S.
Permanent Alien Resident
Other (specify):
FORM GWC-101a: AUTHORIZATION for MEDICAL EXAMINATION and/or TREATMENT (Revised 3/2014)
ATTENDING PHYSICIAN'S REPORT OF INJURY AND TREATMENT
INSTRUCTIONS TO PHYSICIAN: This initial report should be completed and mailed within 20 days, the original to the
Commissioner (see item 13 for address), with a copy to the Company in item 14. Subsequent reports should be made regularly on
Form GWC-204 or in narrative form while employee is in your care. Please read Item 9 on the front of this form. PLEASE TYPE
OR PRINT LEGIBLY.
15. What history of injury or disease did Employee give to you?
16. Is there any history or evidence of PRE-EXISTING injury, disease, or physical impairment? [ ] NO [ ] YES (Describe):
17. What are your findings?
18. What is your diagnosis?
19. Do you believe the condition found was CAUSED or AGGRAVATED by the employment activity described? [ ] YES [ ] NO
(Please explain if there is doubt):
20. Did injury require hospitalization? [ ]YES [ ]NO
Hospital:
Admission date:
Discharge date:
21. Is additional hospitalization required? [ ] YES [ ] NO
22. Surgery (If any, please describe):
Date performed:
23. Other types of treatments:
24. What PERMANENT DEFECTS do you anticipate?
25. Date of first examination:
26. Dates of treatments:
27. Date of discharge:
28. Period of TEMPORARY DISABILITY
(Indicate if unknown):
Partial Disability: From To
Total Disability: From To
29. Date Employee was able to resume work:
LIGHT WORK [ ]
REGULAR WORK [ ]
30. If Employee is able to resume work, date when advised:
31. If Employee is able to resume only light work, indicate extent of PHYSICAL LIMITATIONS and type of work he could reasonably perform with
limitations:
32. General remarks and RECOMMENDATIONS for future care, if indicated:
33. Do you SPECIALIZE? [ ] NO [ ] YES (Please specify):
22 GCA §9132 “Any person who willfully makes any false or misleading statement or representation for the purpose of obtaining any benefit or
payment under this Title, or for the purpose of evading liability for any benefit or payment under this Title, shall be guilty of a misdemeanor.”
34. Name & Signature of Physician:
35. Address:
36. Date of report:
Date/Period of treatment(s)
Service/Supplies
(MUST be itemized)
Quantity
Unit
Price
Amount
Form GWC-101b Revised (3/2014)
WORKER'S COMPENSATION COMMISSION
Department of Labor * Government of Guam
P. O. Box 9970 Tamuning, Guam 96931
Tel: (671) 300-4571/77 Fax: 671-475-6811
WCC File #:
INSTRUCTIONS: This form may be used by the Employee to file a NOTICE of an injury, illness or in the case of death, by Employee's representative. No
benefits need be paid without this notice. Notice shall be given to the Commissioner and to the Employer by delivery or to the last known place of business.
22 GCA 9113. PLEASE PRINT OR TYPE.
** THIS IS NOT A CLAIM **
1. Name of injured Employee, DOB, & SSN: - -
2. Name of Employer & EIN:
3. Employee's address & telephone no: ( )
4. Employer's address:
5. Date & time of alleged injury/illness: 6. Did employee stop work?
If so, date stopped:
7. Employee's occupation:
8. Name of supervisor at time of injury:
9. Place where injury occurred:
10. Is another person not of your employment the cause of the
accident?
[ ] YES [ ] NO
11. Will you file suit against the other person?
[ ] YES [ ] NO
12. DESCRIBE IN FULL HOW THE ACCIDENT OCCURRED: Relate the events which resulted in the injury/illness. Tell what the
Employee was doing at the time of the accident. Tell what happened and how it happened. Name any object or substance involved and tell
how they were involved. Give full details on all factors which led or contributed to the accident. Use additional sheets if required and attach
to this report.
13. Effects of the injury (Indicate parts of body affected and how affected).
22 GCA §9132 “Any person who willfully makes any false or misleading statement or representation for the purpose of obtaining any benefit or
payment under this Title, or for the purpose of evading liability for any benefit or payment under this Title, shall be guilty of a misdemeanor.”
14. Name & signature of person completing this notice:
15. Date of this notice:
FOR STATISTICAL PURPOSES ONLY
Please choose ONE ETHNICITY: Please choose ONE CITIZENSHIP:
Yapese Marshallese American
Chuukese Palauan African American
Kosraean Guamanian Japanese
Pohnpeian Filipino Korean
Chinese Other (specify):
United States
Permanent Resident Alien
Other (specify):
Form GWC-201: NOTICE of EMPLOYEE'S INJURY/ILLNESS or DEATH (Revised 3/2014)
WORKER'S COMPENSATION COMMISSION
Department of Labor * Government of Guam
P.O. Box 9970, Tamuning, Guam 96931
Tel: (671) 300-4571/77 Fax: (671) 475-6811
WCC File #:
INSTRUCTIONS: This form may be used by the Employer to report an injury or illness. 22 GCA 9131 requires the Employer to report to the Commissioner
within ten (10) days from the date of or knowledge of any injury or illness. Failure or refusal to file this report may subject the Employer to a penalty of up to
$500.00. PLEASE PRINT OR TYPE.
1. Name of injured Employee, DOB & SSN:
2. Name of Employer & EIN:
3. Employee's address & telephone no: ( )
4. Employer's address & Telephone no.: ( )
5. Date & time of alleged injury/illness:
6. Date of Employer's first knowledge of injury:
7. Date & hour Employee first lost time because of injury/illness:
8. Date & hour Employee returned to work:
9. Date & hour pay stopped:
10. Days usually worked per week (x days): S M T W TH F S
Average hours per week:
11. Employee's occupation:
12. Employee's wages/earnings (overtime, etc):
13. Is another person not of your employment caused the accident?
[ ] YES [ ] NO
a. Hourly: $
b. Weekly: $
14. DESCRIBE IN FULL HOW THE ACCIDENT OCCURRED: Relate the events which resulted in the injury/illness. Tell what the injured was doing at the
time of the accident. Tell what happened and how it happened. Name any object or substance involved and tell how they were involved. Give full details on
all factors which led or contributed to the accident. Use additional sheets if required and attach to this report.
15. NATURE OF INJURY/ILLNESS (Name part of body affected - fractured leg, bruised arm, lacerated finger, etc) Note any amputations.
16. Has medical attention been
authorized?
[ ] YES [ ] NO
17. Date authorized:
18. Has insurance carrier been
notified?
[ ] YES [ ] NO
19. Date notified:
20. Name of treating physician:
21. Name of insurance carrier:
Worker’s Compensation Commission c/o Guam Dept of Labor
22. Name of treating facility:
23. Name & signature of person completing report:
22 GCA §9132 “Any person who willfully makes any false or misleading statement or representation for the purpose of obtaining any benefit or
payment under this Title, or for the purpose of evading liability for any benefit or payment under this Title, shall be guilty of a misdemeanor.”
24. Title of person completing report:
25. Date of this report:
FOR STATISTICAL PURPOSES ONLY
Please choose ONE ETHNICITY:
Please choose ONE CITIZENSHIP:
Yapese Marshallese African American
Chuukese Palauan Japanese
Kosraean Chamorro Chinese
Pohnepian Filipino American
Korean Other (specify):
United States
Permanent Resident Alien
Other (specify):
Form GWC-202: EMPLOYER'S REPORT of OCCUPATIONAL INJURY or ILLNESS (Rev 3/1/2014)
PLEASE CIRCLE THE APPROPRIATE ITEMS (for statis tical purpos es)
A. EVENT CODE
01 Fatality
02 No Time Loss
03 Time Loss
B. NATURE OF INJURY CODE
01 Amputation
02 Asphyxia
03 Bruise/Contusion/Abrasion
04 Burn (Chemical)
05 Burn (Heat)
06 Concussion
07 Cut/Laceration/Puncture
08 Disease/Illness
09 Dislocation
10 Electric Shock
11 Exertion
12 Foreign Body in Eye/Conjunctivitis
13 Fracture
14 Freezing/Frostbite
15 Hearing Loss
16 Hernia
17 Poisoning (Systemic)
18 Puncture
19 Radiation Effects
20 Strain/Sprain
21 Other (Specify)
C. BODY PART CODE LEFT | RIGHT
Abdomen
Ankle(s):
Back
Body
System
Chest
Head
Ear(s)
Eye(s)
Face
01
02
04
05
06
07
08
09
11
13
03
10
12
Thumb
Fingers Index-Small
(First-Fourth)
Wrist
Hand
Elbow
Arm
Shoulder
14
16 17 18
19
24
26
28
30
32
15
20 21 22
23
25
27
29
31
33
Great Toe
Toes
(First-Fourth)
Ankle
Foot
Knee
Leg
Hip(s)
34
36 37 38 39
44
46
48
50
52
35
40 41 42 43
45
47
49
51
53
D. TYPE OF EVENT CODE
01 Absorption
02 Bite/Sting/Scratch
03 Cardio-Vascular/Respiratory
System Failure
04 Caught In or Between
05 Fall (Same level)
06 Fall (From elevation)
07 Ingestion
08 Inhalation
09 Repeated Motion/Pressure
10 Rubbed/Abraded
11 Shock
12 Struck Against
13 Struck By
14 Other (Specify)
E. SOURCE INJURY CODE
01 Aircraft
02 Air Pressure
03 Animal/Insect/Bird/Reptile/Fish
04 Boat
05 Bodily Motion
06 Boiler/Pressure Vessel
07 Boxes/Barrels, Etc.
08 Buildings/Structures
09 Chemical Liquid/Vapor
10 Cleaning Compound
11 Cold (Environment/Mechanical)
12 Dirt/Sand/Stone
13 Drugs/Alcohol
14 Dust/Particles/Chips
15 Electrical Apparatus/Wiring
16 Explosives
17 Fire/Smoke
18 Food
19 Furniture/Furnishings
20 Gases
21 Glass
22 Hand Tool (Manual)
23 Hand Tool (Powered)
24 Heat (Environmental/Mechanical)
25 Hoisting Apparatus
26 Ladder
27 Machine
28 Materials Handling Equipment
29 Metal Products
30 Motor Vehicle (Highway)
31 Motor Vehicle (Industrial)
32 Motorcycle
33 Person
34 Petroleum Products
35 Pump/Prime Motor
36 Radiation
37 Vegetation
38 Waste Products
29 Water
40 Weapons
41 Working Surface
42 Other (Specify)
F. CONTRIBUTING ENVIRONMENTAL FACTOR CODE
01 Catch Point/Pointer Action
02 Chemical Action/Reaction Exposure
03 Flammable Liquid/Solid Exposure
04 Flying Object Motion
05 Gas/Vapor/Mist/Fume/Smoke/Dust Condition
06 Illumination
07 Materials Handling Equipment/Method
08 Overhead Moving and/or Falling Object Action
09 Overpressure/Underpressure Condition
10 Pinch Point Action
11 Radiation Condition
12 Shear Point Action
13 Sound Level
14 Squeeze Point Action
15 Temperature Above or Below Tolerance Level
16 Weather/Earthquake, Etc. Condition
17 Working Surface/Facility Layout Condition
18 Other (Specify)
G. TASK ASSIGNMENT CODE
01 Employee Working at Regularly Assigned Task(s)
02 Employee Working at OTHER than Regularly Assigned Task(s)
Form GWC-202: EMPLOYER'S REPORT of OCCUPATIONAL INJURY or ILLNESS (Page 2): Rev 3/1/2014