Fillable Form Sorm 29 Employee'S Report Of Injury (Page 2 of 2) in pdf

Form Sorm 29 Employee'S Report Of Injury Page 2

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Instructions

Employee's Report of Injury

Purpose of Form:

The injured employee completes this form to provide SORM with information pertaining to the

circumstances surrounding the injury and what has happened since the date of injury. This will help to

expedite benefits in a more timely manner.

Filing Deadline:

The form must be received by SORM not later than the 5th calendar day after the First Report of Injury

or Illness (DWC-1S) is reported by the agency.

Completed by:

This form shall be completed by the injured employee with assistance from the Claims Coordinator, if

needed.

Instructions:

1. The employee will address each of the questions completely and is to use additional pages if necessary.

The adjuster needs a complete picture of the events surrounding the injury and how the injury

occurred. Witnesses names and phone numbers, physicians/treatment providers names and phone

numbers and work status is needed. The employee should enter any previous workers compensation

claims and the body parts injured.

2. The injured employee will sign and date the form thereby attesting that all information on the form is

true and complete.

Distribution

The Claims Coordinator shall retain the original for the agency file and fax or mail a copy to:

State Office

Risk Management

PO Box 13777

Austin, TX 78711

(512) 472-0228

Notice: With few exceptions, an individual is entitled, upon request, to be informed about the information a state governmental body collects about the individual.

Under Sections 552.021 and 552.023 of the Government Code the individual is entitled to receive and review the information and under Section 559.004 of the

Government Code the individual is entitled to have the state governmental body correct any information about the individual that is incorrect.

SORM 29 Revised 10/14