Oregon Form 801 is a tax form that Oregon residents use to report their income and pay their taxes. The form is fairly straightforward, and most taxpayers will only have to complete a few of the sections. If you need help completing your Oregon Form 801, you can consult with an accountant or tax specialist. In most cases, you will need to submit your completed form by April 15th.
Below are some specifics about oregon form 801. You may find out its size, the typical time necessary to fill out the form, the fields you'll need to fill in, and so forth.
Question | Answer |
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Form Name | Oregon Form 801 |
Form Length | 5 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 1 min 15 sec |
Other names | form 801, 801 form, oregon workers comp claim form, oregon 801 form |
OREGON
Workers' Compensation Division
Workers' Compensation Claim Form 801
Notice to worker: Failure to file a claim with your employer within 90 days of injury or within one year of learning you have
an occupational disease may result in claim denial. Please read about your rights and responsibilities on the back of this form. Notice to employer: Failure to report a claim to your insurance company within five days of knowledge of the claim may
result in untimely payment of
Guidelines for completing the 801
Use a ballpoint pen, press firmly, and write clearly, or use a typewriter. The numbered items
below correspond to those on the 801 and may help you complete the claim form.
Worker section
7.Enter the number of years of education you have completed (GED is 12.)
8.If you were hospitalized past midnight for treatment and lodging, check "Yes."
9.Provide the type of injury (example: cut leg, broken arm).
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Identify the body part(s) injured (example: low back, leg - right, shoulder - left, etc.). |
13.Provide the actual date of accident, if an injury, or the date your condition first required medical attention,
if an occupational disease.
15.If "Yes," briefly describe the prior injury (example: car accident in 1995, work injury in 1996, etc.).
17.Describe the accident as completely as possible. This will help the insurance company handling your claim.
18.Read "Important information about your Social Security Number (SSN)," "Authorization to release medical
records," and "Caution against making false statements," on the back of the 801.
Employer section
20. A Business Identification Number (BIN) is assigned by the Oregon Department of Revenue and is printed on your Oregon Tax Coupons (OTCs).
22. FEIN is your Federal Employers Identification Number.
a client.
28.Examples: truck manufacturing, retail grocery, log hauling, etc.
29.Enter the payroll class code under which you report this worker's earnings to your workers' compensation insurer.
33.Report the earliest of the following:
•the date you first knew of a claim
•the date you first knew of an accident or disease that may result in a compensable injury that requires medical services or causes time loss, permanent disability, or death.
37.See
50.Examples: "Loading dock, north end" or "Client's office at 452 Monroe Street, Washington, D.C., 20210."
51.Examples: acetylene cutting torch, metal plate.
52.Example: "Cutting metal plate for flooring." (Indicate whether or not activity was part of normal job duties.)
53.Example: "Worker stepped back to inspect work and slipped on some scrap metal. As she fell, worker brushed against the hot metal."
56.Check "Yes" if the worker presented a Preferred Worker Eligibility Card to you at the time of hire or you received a "Notice of Premium Exemption" from the Workers' Compensation Division (and the injury occurred on or before the eligibility end date on the card or notice).
Si Ud. tiene preguntas relacionadas a este formulario, |
If you have questions about this form, call the |
comuníquese con la División de Compensación para |
Workers' Compensation Division, Benefits Section, |
Trabajadores, Sección de Beneficios, en Salem al número |
in Salem at (503) |
telefónico (503) |
or |
o (llamada gratis en Oregon) |
(800) |
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801 |
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WC 8468b |
OSHA Recordkeeping Guidelines
Recordable Cases
If you are subject to recordkeeping regulations, you are required to record information on OSHA Form 200 about: (1) every occupational fatality; (2) every nonfatal occupational illness; and (3) those nonfatal occupational injuries that involve one or more of the following: loss of consciousness, restriction of work or motion, transfer to another job, or medical treatment other than first aid (see guidelines below).
Nature of injury |
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Medical treatment (recordable) |
First aid |
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Cuts, lacerations, punctures, |
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Sutures (stitches) |
· Bandaging on any visit to doctor or nurse |
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· Butterfly adhesive dressing(s) or steri strip(s) in |
· Application of antiseptic on first visit to |
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abrasions, splinters |
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lieu of sutures |
doctor or nurse |
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Treatment of infection |
· Application of ointments on first or |
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· Application of antiseptic on second or |
subsequent visits to prevent drying or |
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subsequent visit to a doctor or nurse |
cracking of skin |
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· Removal of foreign bodies requiring skilled |
· Removal of foreign bodies from wound by |
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services of physician due to depth of |
tweezers or other simple techniques |
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embedment, size or shape of object(s), or |
· Removal of foreign bodies in the eye, not |
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location of wound |
embedded, by irrigation |
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· Removal of foreign bodies embedded in eye |
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· Cutting away dead skin (surgical debridement) |
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Fractures |
· Where |
· When |
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Application of a cast or other professional |
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negative for fracture |
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means of immobilizing the injured part is |
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required |
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Strains, sprains, dislocations |
· Application of a cast or other professional |
· Use of an elastic (Ace) bandage on a strain |
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means of immobilizing injured part |
that is not otherwise recordable, on a first |
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Any strain, sprain, or dislocation is recordable if |
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Use of hot or cold compresses for treatment of |
visit to a doctor or nurse |
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the worker's range of motion is affected in a |
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strains, sprains, and dislocation on second or |
· Use of hot or cold compresses for |
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manner that prevents the worker from doing |
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subsequent visits to a doctor or nurse |
treatment of a strain on first visit to a |
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regularly assigned duties, whether or not |
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Use of diathermy and whirlpool treatments on |
doctor or nurse |
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medical treatment is rendered. |
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second or subsequent visits to a doctor or nurse |
· Use of diathermy and whirlpool treatments |
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· A series of chiropractic treatments |
on first visit to doctor or nurse |
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· A single chiropractic treatment for minor |
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injury or discomfort |
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Thermal or chemical burns |
· Treatment of all second- and |
· Treatment by a doctor or nurse for a first- |
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degree burn |
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Any burn is recordable if the worker's range of |
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motion is affected in a manner which prevents |
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the worker from doing his or her regularly |
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assigned duties, whether or not medical |
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treatment is rendered. |
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Bruises, contusions |
· Treatment of a bruise by draining collected |
· Soaking or application of cold compresses |
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blood |
to a bruise, that is otherwise not |
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Any bruise or contusion is recordable if the |
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Soaking or application of cold compresses to a |
recordable, on first visit to a doctor or |
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worker's range of motion is affected in a |
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bruise on second or subsequent visits to a |
nurse |
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manner that prevents the worker from doing |
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doctor or nurse |
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regularly assigned duties, whether or not |
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medical treatment is rendered. |
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Miscellaneous procedures |
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Medical treatment is only one criteria for determining recordability. Any injury that required only
• Tetanus shots, either initial shots or boosters, are considered• All diagnosed occupational illnessesare recordable. preventive in nature and are not considered medical treatment.
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Hospitalization for observation, where no treatment is rendered other |
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All occupational fatalities are recordable. |
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than first aid, is not considered medical treatment. However, most |
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A heart attack, if determined to be |
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injuries requiring hospitalization will result in lost workdays and will be |
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illness |
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recordable for that reason. |
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(col 7g and col 8 of log). |
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The observation of injuryby a doctor or nurse is not recordable. |
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Replacement of broken eyeglasses in itself is not recordable. |
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•Giving worker prescriptions for drugs on second or subsequent visits constitutes medical treatment. Use of prescription medication, when a single dose is administered on the first visit for minor injury or discomfort, is not recordable. Recommending or giving nonprescription medicines is considered first aid.
OSHA recordkeeping questions may be referred to:
Department of Consumer & Business Services,
Information Management Division
350 Winter St. NE, Salem, OR
Phone: (503)
State of Oregon |
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FEIN of claim administrator: |
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Workers' and Employer's |
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Report of Occupational |
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Complete all items — Failure to do so may delay beneftis |
Insurer claim number: |
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Injury or Disease |
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back. |
1. Worker's legal name (first, m.i., last): |
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Home phone: |
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Date of birth: |
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Social Security number (see back of form): |
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5. Worker's street, mailing, and |
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Male |
Female |
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Education - |
grade |
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Hospitalized overnight as inpatient? |
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address: |
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completed: (0 – 20) |
(If emergency room - only, mark "No") |
Yes |
No |
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Nature of injury/disease |
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10. Name and city of hospital: |
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information |
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(strain, cut, bruise, etc.): |
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13. Date of injury/disease: |
14. Time of injury: |
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15. Has body part been injured before? |
(If yes, explain) |
16. Full name, address, and phone of attending |
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11. Body part(s) affected: |
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Left |
12. Name and address of health insurance |
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Right |
provider: |
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See |
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p.m. |
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Yes |
No |
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physician: |
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17. Describe accident fully (please print): |
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WORKER |
Witness(es): |
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18. By my signature I am giving NOTICE OF CLAIM and authorizing medical providers and other custodians of claim records to release relevant |
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medical records. I certify that the above information is true to the best of my knowledge and belief (see paragraphs 3 and 4 on the back). By my |
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signature, I also authorize the use of my SSN as described in paragraph 2 on the back. (If you do not authorize the use of your SSN as described |
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in paragraph 2, check here |
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Worker: Sign and give form to your employer for completion |
X |
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EMPLOYER |
19. Employer's legal business name: |
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20. Employer BIN: |
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Worker signature |
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Date |
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Employer: Complete items |
Dept. use |
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21. Employer's street and |
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22. Employer FEIN: |
24. Client's legal business name: |
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25. Client BIN: |
Emp no |
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23. Insurer Policy #: |
26. Client's street and |
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27. Client FEIN: |
Ins no |
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address: |
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28. Nature of business: |
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29. Worker class code: |
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requirements. |
30. |
Worker's occupation (do not abbreviate): |
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31. Is worker owner or |
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Address of injury site if different from 21 or 26: |
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corp. officer? Yes No |
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33. |
Date employer first knew of claim: |
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34. |
If fatal, date of death |
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Date of hire: |
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36. State of hire: |
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Injured on employer's or client's premises? |
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Yes |
No |
Unknown |
Event |
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recordkeeping |
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38. |
Did injury occur during course of job? |
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Yes |
No |
Unknown |
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39. |
Date left work: |
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Time left work: |
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Date returned to regular work: |
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Source |
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Date returned to work with restrictions/light duty: |
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43. |
Working |
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44. No. of hours worked per |
45. If returned to work with restrictions, |
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shift: |
to |
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shift: |
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were full wages paid? |
Yes |
No |
object |
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Wage and wage period: |
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If wage varies or includes other earnings |
(tips, room and board, commission, etc.) give |
Insurer use |
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per |
Wk. |
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Yr. total weekly wage and explain |
: (Attach payroll records for last 52 weeks prior to date of injury) |
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48. Scheduled days off: |
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No. of days |
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worked per week: |
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S M T W T F |
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OSHA |
50. |
Department and location where event |
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All equip., materials, or chemicals employee was using when event |
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occurred: |
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occurred: |
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satisfies |
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Specific activity the employee was engaged in when event occurred. |
(Indicate if activity was part of normal job duties): |
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How injury or illness occurred; describe the sequence of events and include any objects or substances that directly injured the employee or |
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made the employee ill: |
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form |
54. Was accident caused by person |
(other than |
55. Were other workers injur- |
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56. Is worker "premium exempt" |
(a Preferred Worker)? |
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injured worker) or by failure of machinery or |
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ed in the accident? |
Yes |
No |
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product? |
Yes |
No |
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Yes |
No (If "Yes," attach copy of eligibility card.) |
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This |
57. Signature of employer representative: |
58. Print name, title and phone: |
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59. Date: |
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Attention: Fatalities must be reported to
local field office. Report fatalities or accidents by calling (503)
Original and copy to insurer within 5 days of notice of claim; |
copy to worker immediately as receipt of claim; copy to employer's file. |
WC 8468b
Notice to Worker
Important information about your Social Security Number (SSN)
1.You must provide your SSN. The Workers' Compensation Division (WCD) of the Department of Consumer and Business Services (DCBS) has authority to request your SSN under the Privacy Act of 1974, 5 USC & 552a (West 1977), Section 7(a)(2)(B). Authority under state law is provided in Oregon Revised Statute 656.265, and under Administrative Order WCB
2.Your voluntary authorization for the use of your SSN is also requested for use by various government agencies to carry out their statutory duties, including, but not limited to, planning, research, child support enforcement, employment assistance, benefit coordi- nation, child labor law enforcement, risk management, hazard identification, rate setting, and training programs. If you do not authorize this use, please check the box by your signature in Section 18 on the front of this form.
Authorization to release medical records
3.By signing this 801, you are giving "Notice of Claim" and authorizing medical providers and other custodians of claim record to release records related to the injury or disease claimed on this 801 under ORS Chapter 656 and OAR Chapter 436. Medical information relevant to the claim includes past history of the complaints or treatment of a condition similar to that presented in the claim or other conditions related to the same body part.
Caution against making false statements
4.Any person who knowingly makes any false statement or representation for the purpose of obtaining any benefit or payment is punishable, upon conviction, by imprisonment for a term of not more than one year, a fine of not more than $1,000, or both, under ORS 656.990(1).
This is your receipt, when signed by your employer, that you gave notice of a claim. Keep it as your record.
5.Your employer will submit the claim for you. You will receive written notice from your employer's insurer of any action taken on
your claim. If your employer is
Medical care
6.If your claim is accepted, the insurer or
You must tell your doctor or hospital on your first visit that your injury or illness is work related. The doctor must tell you if there are any limits to the medical services he or she may provide you under the Oregon workers' compensation system.
If you are enrolled in a managed care organization (MCO), your attending physician may be any medical service provider authorized by contract with the MCO. An MCO contracts with insurance companies to provide managed medical care to injured workers of employers covered by the insurance company. Check with the MCO to find out who can be your attending physician. If you are not enrolled in an MCO, your attending physician must be one of the following:
•A licensed medical doctor, a licensed doctor of osteopathy, or a licensed oral and maxillofacial surgeon
•A licensed chiropractor (only for 30 days from the date of the first chiropractic visit on the initial claim or for 12 chiropractic visits during the
Payments for time lost from work
7.In order for you to receive payments for time lost from work, your attending physician must notify the insurer or
If you are disabled for more than three calendar days, the insurer or
If you have questions about your claim that are not resolved by your employer or insurer, you may contact:
Workers' Compensation Division |
OR |
350 Winter Street NE, Room 27, Salem, OR
or
Ombudsman for Injured Workers
350 Winter Street NE, Salem, OR
(503)
UNIFORM INFORMATION SERVICES, INC. WC 8468b |
OREGON
Understanding workers' compensation claims
A guide for workers recently hurt on the job
Workers' Compensation Division
You have received this information because you are filing a workers' compensation injury claim (Form 801) with your employer. If you have additional questions, please do one or more of the following:
Contact your employer's workers' compensation insurer to find out what decisions have been made about your claim and what you need to do to get benefits.
Call the Ombudsman for Injured Workers for help understanding your rights and responsibilities, (503)
Call the Workers' Compensation Division (WCD) for general information about benefits,
(503)
Contact the insurer or the Workers' Compensation Division at the phone number above and ask for the brochure "What happens if I'm hurt on the job?." The insurer will send this automatically if you are disabled by your injury.
What do I do now?
Tell your doctor that you were hurt on the job. Your doctor will ask you to fill out a Form 827 - "First report of injury/disease." Your doctor will send the Form 827 to the insurer for you.
May I get treatment from any doctor?
Unless the insurer has enrolled you in a managed care organization (MCO), you may treat with any doctor who qualifies as an attending physician under Oregon law. Your doctor will tell you if there are any limits to the services he or she can provide.
What are my doctor's responsibilities?
Your doctor is in charge of your medical treatment. Only your doctor can authorize time off work, reduce work hours or duties, or release you to go back to work.
Will my employer's insurer pay my medical bills?
If your claim is accepted, the insurer will pay injury- related medical bills. Save your receipts for pre- scription medications, transportation, and other bills you pay for
If I can't work, will I receive payments from the insurer for lost wages?
Yes, if your doctor notifies the insurer that you cannot work or cannot do your regular work due to your injuries, you will receive temporary disability payments. However, Oregon law requires a
What can I do to make sure I receive benefits to which I am entitled?
•Find out the legal business name of your employer and the name of its workers' compensation insurer. If you have a problem getting this information, call the Workers' Compensation Division Employer Index, (503)
•Keep all medical appointments.
•Read and keep copies of all letters and forms you receive regarding your claim.
•Keep track of phone calls, including with whom you speak, subject matter, and dates.
•Observe all deadlines. Do not be late to submit information or to file appeals.
•Contact your employer immediately when your doctor releases you for work.
•Contact the insurer if you have questions.
WC 8468b