Employer'S Form Instructions/definitions

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EMPLOYER'S FORM INSTRUCTIONS/DEFINITIONS
The use of this form is required by the Delaware Workers' Compensation Statute, 19 Del.C. §2322E,
to report all information specific to this workers' compensation injury.
Complete all applicable fields.
1. Case Information:
Employer Name: The name of the employer associated with the claim.
Employee Name: Name of the injured worker.
Modification Duty Information: Complete all applicable fields
Employer Fax: The telephone and fax numbers of the employer.
Job Title: Provide job title for position available.
Job Description: Provide description of physical requirements of job duties for position available.
Environment/Working Conditions: Identify any environmental factors relevant to position available.
2. Hours Per Day Job Available: Circle the number of hours applicable.
3. Additional Information: Circle the applicable work status categories for the position available, and comment as
appropriate in the space provided regarding the work postures/positional requirements for the modified duty job available.
4. Employer: Provide job availability date.
5. Comments: To be used to explain/clarify any information required by this form.
6. Employer Information: The person responsible for completing this form on behalf of the employer must sign and
date this form.
WITHIN FOURTEEN (14) DAYS OF RECEIVING THE INITIAL “PHYSICIAN’S REPORT OF WORKERS’
COMPENSATION INJURY,” THE EMPLOYER SHALL PROVIDE THIS FORM TO THE HEALTH CARE
PROVIDER/PHYSICIAN WHO ISSUED THE AFOREMENTIONED REPORT AND THE EMPLOYER’S
INSURANCE CARRIER AS REQUIRED BY 19 DEL.C. §2322E(D).
IF THE “PHYSICIAN’S REPORT OF WORKERS’ COMPENSATION INJURY” RELEASES THE EMPLOYEE
TO FULL DUTY, DO NOT COMPLETE THIS FORM.
THE HEALTH CARE PROVIDER/PHYSICIAN MUST COMPLETE HIS/HER PORTION OF THIS FORM
AND SIGN AND RETURN IT TO THE EMPLOYER WITHIN FOURTEEN (14) DAYS OF THE NEXT DATE
OF SERVICE AFTER THE PHYSICIAN'S RECEIPT OF THE FORM FROM THE EMPLOYER, BUT NOT
LATER THAN TWENTY-ONE (21) DAYS FROM THE PHYSICIAN'S RECEIPT OF SUCH FORM.
EMPLOYER FORM
Revised 8/17/2011

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