Form 1 - State Of Delaware First Report Of Occupational Injury Or Disease (Page 5 of 6) in pdf

Form 1 - State Of Delaware First Report Of Occupational Injury Or Disease Page 5

Form #3:

State of Delaware Workers' Compensation Employer’s Modified Duty Availability Report

Contact Labor Relations at 302-831-8305 if you have questions or need assistance with this form.

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.

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.

Hours Per Day Job Available: Circle the number of hours applicable.

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.

Employer: Provide job availability date.

Comments: To be used to explain/clarify any information required by this form.

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 A NOTICE OF INJURY, THE EMPLOYER SHALL

PROVIDE THIS FORM TO THE INJURED WORKER’S HEALTH CARE PROVIDER/PHYSICIAN AND THE

EMPLOYER’S INSURANCE CARRIER AS REQUIRED BY 19 DEL.C. §2322E(d).

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.

Form 1 - State Of Delaware First Report Of Occupational Injury Or Disease Page 5