Form Dol-Lm-101 - South Dakota Employer'S First Report Of Injury - 2008 Page 2
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1
2GENERAL INSTRUCTIONS
EMPLOYEE
1.
Notify employer immediately of injury, as required by SDCL 62-7-10.
2.
Complete all questions in the EMPLOYEE and INJURY/TREATMENT sections.
3.
Sign the form.
4.
Submit this form to your employer within three (3) business days after the injury.
EMPLOYER
1.
Complete all questions in the EMPLOYER/EMPLOYMENT sections.
2.
Sign the form.
3.
Submit this form to your workers’ compensation insurance carrier within seven (7) days of knowledge of the occurrence of the
injury, as required by SDCL 62-6-2.
4.
Give a copy of the form to the injured employee.
5.
Keep the copy of the First Report of Injury for at least four (4) years from the date of injury, as required by SDCL 62-6-1.
INSURER
1.
Complete all questions in the CLAIM OFFICE INFORMATION sections at the bottom of the page.
2.
Submit this form within ten (10) days of its receipt, as required by SDCL 62-6-3, to:
SOUTH DAKOTA DEPARTMENT OF LABOR
Division of Labor and Management
700 Governors Drive
Pierre SD 57501-2291
Tel. (605) 773-3681
BODY PART CODES
02
Blindness one eye
44
Chest, including ribs sternum, soft ribs
78
Ring finger at metacarpal bone
03
Blindness both eyes
48
Internal organs-other than heart, lungs
79
Ring finger at proximal joint
04
Deafness both ears
49
Heart
80
Ring finger at middle joint
05
Deafness one ear
51
Hip
81
Ring finger at distal joint
10
Multiple head injury
52
Upper leg
82
Little finger at metacarpal bone
11
Skull
53
Knee
83
Little finger at proximal joint
12
Brain
54
Lower leg
84
Little finger at middle joint
13
Ear(s)
55
Ankle
85
Little finger at distal joint
14
Eye(s)
56
Foot
86
Great toe metatarsal bone
17
Mouth
57
Toe (other than greater)
87
Great toe at proximal joint
19
Face (facial bones)
58
Toe (greater)
88
Great toe at distal joint
20
Multiple neck injury
60
Lungs
90
Multiple injury
21
Vertebrae
61
Groin
92
Other toe metatarsal bone
22
Disc
67
Thumb metacarpal bone
93
Other toe at proximal joint
24
Other
68
Thumb at proximal joint
94
Other toe at middle joint
31
Upper arm
69
Thumb at distal joint
95
Other toe at distal joint
32
Elbow
70
Index finger at metacarpal bone
96
Little toe metatarsal bone
33
Lower Arm-forearm
71
Index finger at proximal joint
97
Little toe at distal joint
34
Wrist
72
Index finger at middle joint
35
Hand
73
Index finger at distal joint
37
Thumb
74
Middle finger at metacarpal bone
38
Shoulder
75
Middle finger at proximal joint
41
Upper Back
76
Middle finger at middle joint
42
Lower Back
77
Middle finger at distal joint
CAUSE OF INJURY CODES
NATURE OF INJURY CODES
01
Body reaction/over
70
Striking against or stepping on
reaction (includes
00
Not applicable
chemicals)
01
Allergy
03
Temperature extremes
78
Struck or injured by moving parts of machine
02
Disfigurement
13
Caught in/under/between
81
Struck or injured, includes knife or sharp
71
Occupational disease
object, kicked, bit, etc. – struck by object,
72
Hearing loss
worker, patient, etc.
25
Fall from elevation
89
Hostile attack-person in act of crime
29
Fall from same level
90
Other than physical cause of injury
50
Motor vehicle
94
Repetitive motion – callous, blister, etc.
56
Bending/Lifting
97
Repetitive motion-carpal tunnel syndrome,
etc.
65
Machinery/Equipment
99
Other
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