Accident Report Form - Kansas Department Of Labor -2013 Page 2
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2Kansas Department of Labor
Page 2 of 2
Accident Report
K-WC 1101-A (Rev. 10-13)
Instructions
You must answer every question; failure to answer all questions may cause the report to be returned to the
employer. Returned accident reports may cause a delay of benefits to the injured employees and could subject the
employer to fines.
The employer must send this accident report to its insurance carrier, third party administrator or pool association
for electronic submission to the Kansas Department of Labor Division of Workers Compensation.
*Instructions for Questions 14 and 15
14: Name the object or substance which directly injured the employee. Example: machine or object employee
struck or struck employee; vapor or poison employee inhaled or swallowed; chemicals or radiation which
irritated employee's skin; if hernia, the object employee was lifting or pulling; etc.
15: Be as specific as possible indicating all that is known about the injury. Name the part of body injured.
Definition of an Incapacitating Injury
The Workers’ Compensation Act sets forth a strict time frame for filing accident reports with the division. The
controlling statute is K.S.A. 44-557(a), which reads as follows:
(a) it is hereby made the duty of every employer to make or cause to be made a report to the
director of any accident, or claimed or alleged accident, to any employee which occurs in the
course of the employee’s employment and of which the employer or the employer’s supervisor
has knowledge, which report shall be made upon a form to be prepared by the director, within 28
days, after the receipt of such knowledge, if the personal injuries which are sustained by such
accidents are sufficient wholly or partially to incapacitate the person injured from labor or service
for more than the remainder of the day, shift or turn on which such injuries were sustained.
Accident reports are not required for every work-related injury. The statute requires a report to be filed when the
worker's whole or partial incapacity continues beyond the "day, turn, or shift which such injuries are sustained"
as the result of accident. "Incapacity" is not specifically defined within the law, but the division believes that the
Legislature's intent was to reference a worker's whole or partial loss of the ability to perform his or her ordinary
job tasks. When in doubt, keep in mind the law contains no penalty for filing a report that ultimately proves to be
unnecessary. There are penalties, however, for failing to file a report when one was required. The penalties
include fines and limitations on the defenses the employer may assert if a claim is filed.
OSHA Recordkeeping
The employer must complete an Injury and Illness Incident Report, OSHA Form 301, within seven (7) days of
learning that a work-related injury or illness has occurred. According to OSHA's recordkeeping rule, you must keep
Form 301, or an equivalent substitute on file for five (5) years.
To learn more about OSHA's recordkeeping requirements and download forms, visit:
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