Fillable or Illness Report of Job Injury Worker Workers (Eastern Oregon State College)

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or Illness Report of Job Injury Worker Workers (Eastern Oregon State College)

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8. What is your illness or injury? What part of the body? Which side? (Example: sprained right foot)
Left
Right
400 High St. SE, Salem, OR 97312
Email: saif801@saif.com
Toll-free phone: 1.800.285.8525
Toll-free FAX: 1.800.475.7785
CLAIM NO.
SUBJECT DATE
CLASS
DEFAULT DATE
EMPLOYER’S
ACCOUNT NO.
Report of Job Injury
or Illness
Workers’ compensation claim
Worker
To make a claim for a work-related injury or illness, ll out the worker portion of this form and give to your employer. If you do not intend to
le a workers’ compensation claim with SAIF Corporation, do not sign the signature line. Your employer will give you a copy.
DEPT USE:
Emp
Ins
Occ
Nat
Part
Ev
Src
2src
1. Date of injury
or illness:
2. Date you
left work:
3. Time you began work
on day of injury:
4. Regularly scheduled
days off:
M T W T F S S
5. Time of injury
or illness:
7. Shift on (from)
day of injury: (to)
6. Time you
left work:
9. Check here if you have
more than one job:
10. What caused it? What were you doing? Include vehicle, machinery, or tool used. (Example: Fell 10 feet when climbing an extension ladder carrying a 40-pound box of roong materials)
13. Birthdate:
11. Your legal name:
14. Gender:
M F
12. Worker’s language preference other than English:
Spanish Other (please specify):
15. Your mailing address,
city, state and zip:
16. Home phone:
19. Work phone:17. Social Security no. (see back*): 18. Occupation:
20. Names of witnesses:
21. Name and phone number of health insurance company:
23. Have you previously injured this body part? Yes
No
24. Were you hospitalized overnight as an inpatient? Yes
No
25. Were you treated in the emergency room? Yes
No
22. Name and address of health care provider who treated you for the injury or illness you
are now reporting:
26. By my signature, I am making a claim for worker’s compensation benets. The above information is true to the best of my knowledge and belief. I authorize health care providers and other custodians of claim
records to release relevant medical records to the workers’ compensation insurer, self-insured employer, claim administrator, and the Oregon Department of Consumer and Business Services. Notice: Relevant
medical records include records of prior treatment for the same conditions or of injuries to the same area of the body. A HIPAA authorization is not required (45 CFR 164.512(I)). Release of HIV/AIDS records,
certain drug and alcohol treatment records, and other records protected by state and federal law requires separate authorization.
27. Worker
signature:
28. Completed by
(please print):
29. Date:
Employer
Complete the rest of this form and give a copy of the form to the worker. Notify SAIF Corporation within ve days of knowledge of the claim.
Even if the worker does not wish to le a claim, maintain a copy of this form.
31. Phone: 32. FEIN:
34. Client
FEIN:
36. Insurance
policy no.:
38. Nature of business in which worker is/was
supervised:
39. Address where
event occurred:
35. Address of principal place
of business (not P.O. Box):
37. Street address from which
worker is/was supervised: ZIP:
33. If worker leasing company,
list client business name:
30. Employer legal
business name:
40. Was injury caused by failure of a machine or product, or by a person other than the injured worker? Yes
No
41. Class code:
44. OSHA 300 log case no:
42. Were other workers injured? Yes
No
43. Did injury occur during course Unknown Yes
No
and scope of job?
45. Date employer
knew of claim:
46. Worker’s
weekly wage: $
47. Date worker
hired:
48. If fatal, date
of death
53. Date:52. Name and title
(please print):
51. Employer
signature:
49. Return-to-work status: Not returned
50. If returned to modied work,
is it at regular hours and wages?
Regular Modied
Date: Date:
801
X801 3/16
801
OSHA requirements: Employers must report work-related fatalities and catastrophes to Oregon OSHA either in person or by telephone within
eight hours. In addition, employers must report any in-patient hospitalization, loss of an eye, and any amputation or avulsion that results in bone
or cartilage loss to Oregon OSHA within 24 hours. See OAR 437-001-0704. Call 800.922.2689 (toll-free), 503.378.3272, or Oregon Emergency
Response, 800.452.0311 (toll-free), on nights and weekends.
Information ABOVE this line: date of death, if death occurred; and Oregon OSHA case log number must be released to an authorized worker representative upon request.
a.m.
p.m.
a.m.
p.m.
a.m.
p.m.
a.m.
p.m.
a.m.
p.m.
Yes No
For SAIF Customer Use
Area
|
|
Dept.
Shift CC
RESET
PRINT
A guide for workers recently hurt on the job
The following information is provided by SAIF Corporation
at the request of the Workers’ Compensation Division
400 High St. SE, Salem, OR 97312
440-3283 (01/16/DCBS/WCD/WEB) for distribution with X801 SAIF Corporation 3/16
Do I have to provide my Social Security number on Forms 801 and 827? What will it be used for?
You do not need to have an SSN to get workers’ compensation benets. If you have an SSN, and don’t provide it, the Workers’
Compensation Division (WCD) of the Department of Consumer and Business Services will get it from your employer, the
workers’ compensation insurer, or other sources. WCD may use your SSN for: quality assessment, correct identication and
processing of claims, compliance, research, injured worker program administration, matching data with other state agencies to
measure WCD program effectiveness, injury prevention activities, and to provide to federal agencies in the Medicare program
for their use as required by federal law. The following laws authorize WCD to get your SSN: the Privacy Act of 1974, 5 USC
§ 552a, Section (7)(a)(2)(B); Oregon Revised Statutes chapter 656; and Oregon Administrative Rules chapter 436 (Workers’
Compensation Board Administrative Order No. 4-1967).
How do I le a claim?
• Notify your employer and a health care provider of your
choice about your job-related injury or illness as soon as
possible. Your employer cannot choose your health care
provider for you.
• Ask your employer the name of its workers’ compensation
insurer.
• Complete Form 801, “Report of Job Injury or Illness,”
available from your employer and Form 827, “Worker’s
and Physician’s Report for Workers’ Compensation
Claims,” available from your health care provider.
How do I get medical treatment?
• You may receive medical treatment from the health care
provider of your choice, including:
– Authorized nurse practitioners
– Chiropractors
– Medical doctors
– Naturopaths
– Oral surgeons
– Osteopathic doctors
– Physician assistants
– Podiatrists
– Other health care providers
• The insurance company may enroll you in a managed care
organization at any time. If it does, you will receive more
information about your medical treatment options.
Are there limitations to my medical treatment?
• Health care providers may be limited in how long
they may treat you and whether they may authorize
payments for time off work. Check with your health care
provider about any limitations that may apply.
• If your claim is denied, you may have to pay for your
medical treatment.
If I can’t work, will I receive payments for
lost wages?
• You may be unable to work due to your job-related
injury or illness. In order for you to receive payments
for time off work, your health care provider must send
written authorization to the insurer.
• Generally, you will not be paid for the rst three
calendar days for time off work.
• You may be paid for lost wages for the rst three
calendar days if you are off work for 14 consecutive
days or hospitalized overnight.
• If your claim is denied within the rst 14 days, you
will not be paid for any lost wages.
• Keep your employer informed about what is going on
and cooperate with efforts to return you to a modied-
or light-duty job.
What if I have questions about my claim?
• SAIF Corporation or your employer should be able
to answer your questions. Call SAIF Corporation at
800.285.8525.
• If you have questions, concerns, or complaints, you may
also call any of the numbers below:
Ombudsman for Injured Workers:
An advocate for injured workers
Toll-free: 800.927.1271
Email: oiw.questions@oregon.gov
Workers’ Compensation Compliance Section
Toll-free: 800.452.0288
Email: workcomp.questions@oregon.gov
*
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Completed 23 July 2020

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