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Question	Answer
Form Name	Drsxxx
Form Length	4 pages
Fillable?	Yes
Fillable fields	114
Avg. time to fill out	23 min 52 sec
Other names	bwc 1101, first report of injury ohio, ohio bwc froi, ohio bwc froi form

Form Preview Example

First Report of an Injury,

Occupational Disease or Death

This form can be completed and submitted online at

www.bwc.ohio.gov

Report your injury by completing all three sections of this form

1Complete as much of all three sections of this form as possible to reduce the time necessary in determining the claim. If this form is completed by the injured worker at the irst visit to a medical provider, the injured worker may give the FROI to the provider to complete the treatment information section.The provider can then submit the FROI to the MCO.

2Deliver, mail or fax the completed document to your employer or your employer's managed care organization (MCO).

3If you do not know your employer's MCO, contact BWC at 1-800-644-6292 and follow the prompts, or use the MCO on BWC's Web site at www. bwc.ohio.gov.

4If you are unable to determine your MCO, mail or fax this form to the BWC customer service ofice closest to your home. For information on your local customer service ofice, please visit www.bwc.ohio.gov., or call 1-800-644-6292.

Injured workers employed by a self-insuring employer

•Complete this form and give to your employer.

•Your employer should be able to tell you if he or she is a self-insuring employer.

•If your employer is self-insuring and you ile this information with BWC, processing delays may occur.

For assistance in completing this form, call your BWC customer service ofﬁce Monday through Friday, 8 a.m. – 5 p.m.

Cambridge	Dayton	Mansﬁeld
61501 Southgate Road	3401 Park Center Drive, Suite 100	240 Tappan Drive, N., Suite A
Cambridge, OH 43725-9114	Dayton, OH 45414-2577	Ontario, OH 44906-1366
Phone: 740-435-4200	Phone: 937-264-5000	Phone: 419-747-4090
Fax: 866-281-9351	Fax: 866-281-9356	Fax: 866-336-8350

Canton	Garﬁeld Heights	Portsmouth
339 E. Maple St., Suite 200	4800 E. 131 St., Suite A	1005 Fourth St.
North Canton, OH 44720-2593	Garﬁeld Heights, OH 44105-7132	Portsmouth, OH 45662-4315
Phone: 330-438-0638	Phone: 216-584-0100	Phone: 740-353-2187
Toll free: 800-713-0991	Toll free: 800-224-6446	Fax: 866-336-8353
Fax: 866-281-9352	Fax: 866-457-0590
		Toledo
Cleveland	Governor’s Hill	P.O. Box 794
615 Superior Ave. W.	8650 Governor’s Hill Drive	1 Government Center, Suite 1136
Cleveland, OH 44113-1889	Cincinnati, OH 45249-1369	Toledo, OH 43697-0794
Phone: 216-787-3050	Phone: 513-583-4400	Phone: 419-245-2700
Toll free: 800-821-7075	Fax: 866-281-9357	Fax: 866-457-0594
Fax: 866-336-8345
	Lima	Youngstown
Columbus	2025 E. Fourth St.	242 Federal Plaza, W., Suite 200
30 W. Spring St.	Lima, OH 45804-4101	Youngstown, OH 44503-1206
Columbus, OH 43215-2256	Phone: 419-227-3127	Phone: 330-797-5500
Phone: 614-728-5416	Toll free: 888-419-3127	Toll free: 800-551-6446
Fax: 866-336-8352	Fax: 866-336-8346	Fax: 866-457-0596

Completion

Last name, ﬁrst name, middle initial

Social Security number

Marital status

Date of birth

Single

instructions

info.

Home mailing address

Sex

Married

Number of dependents

Male

Female

Divorced

(continued)

City

State

9-digit ZIP code

Country if different from USA

Separated

Department name

Widowed

injury/disease/death

Wage rate

Hour

Month

Week

What days of the week do you usually work?

Regular work hours

$________________ Per: 3

Year

Other _________________

Sun

Mon

Tues

Wed

Thur

Fri

Sat

From ____ To ____ 4

Have you been offered or do you expect to receive payment or wages for this claim from anyone other than the Ohio Bureau

Occupation or job title

of Workers' Compensation? YES

NO If yes, please explain.

Employer name

Mailing address (number and street, city or town, state, ZIP code and county)

Location, if different from mailing address

Was place of accident or exposure on employer's premises? Yes

If no, give accident location, street address, city, state and ZIP code.

Date of injury/disease

Time of injury

If fatal, give date of death

Time employee began

Date last worked

Date returned to work

__________

a.m.

p.m.

work

a.m.

p.m.

Date hired

State where hired

Date employer notiﬁed 12

State where supervised

and

Description of accident (Describe the sequence of events that directly

Type of injury/disease and part(s) of body affected

injured the employee, or caused the disease or death)

(for example: sprain of lower left back, etc.)

worker

and beneﬁts under Ohio's workers’ compensation laws for my claim, and I waive and release my right to ﬁle for and receive compensation and beneﬁts under the laws of any other state for this claim. I request

Injured

payment for compensation and/or medical beneﬁts as allowable, and authorize direct payment to my medical providers. I permit and authorize any provider who attends, treats or examines me, the Ohio State Board

of Pharmacy, the Ohio Department of Job and Family Services and the Ohio Rehabilitation Services Commission to release medical, psychological, psychiatric, pharmaceutical, vocational and social information. I

understand this may include personally identifying information that is casually or historically related to my physical or mental injuries relevant to issues necessary for the administration of my claim to BWC, the

Industrial Commission of Ohio, the employer in this claim, the employer’s managed care organization and any authorized representatives. My previous or future BWC claims may affect decisions made in this claim.

Proper administration of the present claim may require BWC to share claims information with the employers of record (or their authorized representatives) and/or my authorized representative for any and all such

previous or future claims. The released claims information may include any record maintained in my claim ﬁles.

Injured worker signature

Date

E-mail address

Telephone number

Work number

( )

1 Home address: Enter the home address where the

9 Date last worked: Enter the last day worked as a result

injured worker lives. Include the apartment number,

of this injury, occupational disease or death.

if applicable.

• If the post ofice does not deliver mail to the

Date returned to work: Enter the date the injured

home address, list the mailing address instead

worker returned to work after the injury or

of the home address.

occupational disease.

info.

Department name: Enter the injured worker's

11 State where hired: Enter the state where the injured

department or area name where he/she normally

worker was hired by the employer listed on this

reports for work.

application.

injury/disease/death

3 Wage rate: Enter the injured worker's rate of pay, and

12 Date employer notiied: Enter the date the employer

then select how often it is received. (If the pay rate

wasnotiiedoftheinjury,occupationaldiseaseordeath.

being reported is not hourly, report the gross amount.)

• If eight or more days of work will be missed, BWC

13 State where supervised: Enter the state where the

needs wage information for the 52 weeks prior to

injuredworkerwassupervisedbytheemployerlisted

the date of injury. Submit wage information using

on this application.

employer payroll reports, wage statement (BWC

form C-94-A), W-2s, etc.

14 Description of accident: Describe in detail the events

4 What days of the week do you usually work? What

that caused the injury, occupational disease or death.

are your regular work hours: Enter the days and

Attach additional sheets, if necessary.

and

hours the injured worker normally works.

• If the days worked vary from week to week, list the

Type of injury/disease and part of body affected:

worker

number of hours worked in an average week.

Describethenatureoftheinjury,occupationaldisease

Wages:Ifyoureceivedwagesduringdisability,please

or death.

Indicate the part(s) of body injured, affected or that

explain.

caused the death.

Injured

6 Occupationorjobtitle:Entertheinjuredworker'stype

Examples:

• Laceration of irst toe, left foot;

of occupation or actual job title at the time of injury,

• Sprain of lower right back; etc.

occupational disease or death.

16 Injured worker signature (injured workers only):

Employer name: Enter the name of the injured

Please

read

the

Benefit application/medical

worker's

employer at the time of

the

injury,

release information before signing and dating

occupational disease or death.

this form.

8 Date of injury/disease: Enter the date injured worker

was injured. OR

If the injured worker contracted an occupational

Instructions

disease, determine which of the following happened

continued

most recently:

on last page

• The occupational disease was diagnosed by a medical provider;

[

• The irst medical treatment;

• The injured worker irst quit work, due to the occupational disease.

Enter this as the date of occupational disease.

First Report of an Injury, Occupational Disease or Death

By signing this form, I:

•Elect to only receive compensation and/or beneits that are provided for in this claim under Ohio workers' compensation laws;

•Waive and release my right to receive compensation and beneits under the workers' compensation laws of another state for the injury or occupational disease, or death resulting from an injury or occupational disease, for which I am iling this claim;

•Agree that I have not and will not ile a claim in another state for the injury or occupational disease or death resulting from an injury or occupational disease for which I am iling this claim;

•Conirm that I have not received compensation and/or beneits under the workers’ compensation laws of another state for this claim, and that I will notify BWC immediately upon receiving any compensation or beneits from any source for this claim.

WARNING:

Any person who obtains compensation from BWC or self-insuring employers by knowingly misrepresenting or concealing facts, making false statementsoracceptingcompensationtowhichhe or she is not entitled, is subject to felony criminal prosecution for fraud.

(R.C. 2913.48)

Injured worker and injury/disease/death info.

Last name, ﬁrst name, middle initial

Social Security number

Marital status

Date of birth

Single

Home mailing address

Sex

Married

Number of dependents

Male

Female

Divorced

Separated

City

State

9-digit ZIP code

Country if different from USA

Department name

Widowed

Wage rate

Hour

Month

Week

What days of the week do you usually work?

Regular work hours

Per:

Year

Other

Sun

Mon

Tues

Wed Thur

Fri

Sat

From

Have you been offered or do you expect to receive payment or wages for this claim from anyone other than the Ohio Bureau

Occupation or job title

of Workers' Compensation?

Yes

If yes, please explain.

Employer name

Mailing address (number and street, city or town, state, ZIP code and county)

Location, if different from mailing address

Was the place of accident or exposure on employer's premises?

Yes

(If no, give accident location, street address, city, state and ZIP code)

Date of injury/disease

Time of injury

If fatal, give date of death

Time employee

Date last worked

Date returned to work

a.m.

p.m.

began work

a.m. p.m.

Date hired

State where hired

Date employer notiﬁed

State where supervised

Description of accident (Describe the sequence of events that directly

Type of injury/disease and part(s) of body affected

injured the employee, or caused the disease or death.)

(For example: sprain of lower left back)

Beneﬁt application release of information – I am applying for a claim under the Ohio Bureau of Workers’ Compensation Act for work-related injuries that I did not inﬂict. I afﬁrm that I elect to receive compensation and beneﬁts under Ohio's workers’ compensation laws for my claim, and I waive and release my right to ﬁle for and receive compensation and beneﬁts under the laws of any other state for this claim. I request payment for compensation and/ or medical beneﬁts as allowable, and authorize direct payment to my medical providers. I permit and authorize any provider who attends, treats or examines me, the Ohio State Board of Pharmacy, the Ohio Department of Job and Family Services and the Ohio Rehabilitation Services Commission to release medical, psychological, psychiatric, pharmaceutical, vocational and social information. I understand this may include personally identifying information that is casually or historically related to my physical or mental injuries relevant to issues necessary for the administration of my claim to BWC, the Industrial Commission of Ohio, the employer in this claim, the employer’s managed care organization and any authorized representatives. My previous or future BWC claims may affect decisions made in this claim. Proper administration of the present claim may require BWC to share claims information with the employers of record (or their authorized representatives) and/or my authorized representative for any and all such previous or future claims. The released claims information may include any record maintained in my claim ﬁles.

Injured worker signature	Date	E-mail address	Telephone number	Work number
				(	)

Treatment info.

Health-care provider name	Telephone number		Fax number			Initial treatment date
	(	)	(	)
Street address	City				State	9-digit ZIP code

Diagnosis(es): Include ICD code(s)

Will the incident cause the injured worker to
miss eight or more days of work?	Yes	No	Is the injury causally related to the industrial incident?			Yes	No

E code				11-digit BWC provider number	Date

Health-care provider signature

Employer policy number

Check

Employer is self-insuring

Injured worker is owner/partner/member of ﬁrm

Telephone number

Fax number

E-mail address

Federal ID number

Manual number

(

)

(

)

info.

Was employee treated in an emergency room?

Yes No

Was employee hospitalized overnight as an inpatient?

Yes No

Employer

If treatment was given away from work site, provide the facility name, street address, city, state and ZIP code

Certiﬁcation - The employer

Rejection - The employer

For self-insuring employers only

Clariﬁcation - The employer clariﬁes

certiﬁes that the facts in this

rejects the validity of this claim for

application are correct and valid.

the reason(s) listed below:

and allows the claim for the condition(s) below:

Medical only

Lost time

Employer signature and title

Date

OSHA case number

BWC-1101 (Rev. 6/12/2014)

This form meets OSHA 301 requirements

FROI-1 (Combines C-1, C-2, C-3, C-6, C-50, OD-1, OD-1-22)

Completion instructions

(continued)

Treatment info.

Health-care provider name

Telephone number

Fax number

Initial treatment date

(

)

(

)

info.

Street address

City

State

9-digit ZIP code

Diagnosis(es): Include ICD code(s)

Treatment

SAMPLE

E code 3

11-digit BWC provider number

Date

Will the incident cause the injured worker to miss eight or more

days of work?

Yes

Is the injury causally related to the industrial incident?

Yes

Health-care provider signature

1Indicate the diagnosis and ICD codes for conditions being treated as a result of the injury.

2Indicate the treating provider's medical opinion that the injury sustained is causally related to the industrial incident, that the injury could result from the method (manner) of the accident, as described by the injured worker. It must be clear that the diagnosis in all probability occurred as a result of the injury.

3Providing a valid E code will enable us to determine the claim more quickly and eficiently.

4Enter the physician's or health-care provider's 11-digit BWC-assigned provider number.

5Signature of the health-care provider completing this form.

1 Employer policy number

Check

Employer is self-insuring

Injured worker is owner/partner/member of ﬁrm

info.

Telephone number

Fax number

E-mail address

Federal ID number

Manual number

(

)

( )

Was employee treated in an emergency room?

Yes

Was employee hospitalized as an inpatient?

Yes

If treatment was given away from work site, provide the facility name, street address, city, state and ZIP code

Certiﬁcation - The employer

Rejection - The employer

For self-insuring employers only

Employer

certiies that the facts in this

SAMPLE

Clariﬁcation - The employer clariies

rejects the validity of this claim for

application are correct and valid.

the reason(s) listed below:

5 and allows the claim for the condition(s) below:

Employer: signature and title

Date

OSHA case number 6

Employer info.

1Enter the employer's BWC-assigned policy number, which is located on the BWC certiicate of coverage.

2Enter the four-digit code that indicates the injured worker's job classiication, located on the semiannual payroll report.

•If you do not know the injured worker's manual number, call 1-800-644-6292 and follow the prompts.

3If certiication is selected and the claim is allowed, it will promptly be paid. Employers certifying a claim waive both the notice of receipt and notice of irst order of compensation.

4If rejection is selected, use the space provided to list the reasons for rejection. Attach additional sheets, if necessary.

5Self-insuring employers that choose to clarify certiication may use the space provided. Attach additional sheet, if necessary.

6If this is an OSHA-reportable injury, include the case number assigned by the employer.This form meets OSHA 301 requirements and may be used in lieu of the OSHA 301 when reporting recordable injuries and illnesses to the federal government.

Note:

If your employee misses eight or more days of work, BWC will need wage information for the 52 weeks prior to the date of injury. Submit wage information using employer payroll reports, wage statement (BWC form C-94-A), W-2s, etc.

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entering details in ohio bwc froi step 1

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Within the segment discussing Telephone, number Email, address Date, Work, number Healthcare, provider, name Street, address Diagnosis, es, Include, ICD, codes Healthcare, provider, signature Employer, policy, number Telephone, number Fax, number Telephone, number City, Fax, number and Initial, treatment, date one should put down some vital data.

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