Instructions For Completing The Employer Report Of Injury/illness (Ldol-Wc-1007)

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I N S T R U C T I O N S
F O R C O M P L E T I N G
T H E E M P L O Y E R
R E P O R T
O F I N J U R Y / I L L N E S S
( L D O L - W C - 1 0 0 7 )
Please type this form or p r i n t clearly in i n k Items with a n asterisk are required a n d must be completed or y o u r form will be r e t u r n e d . This form
is due within 10 days of y o u r knowledge of a n incident which results in d e a t h or time lost from w o r k in excess of 7 days. It is also due w h e n you
receive notice of a disputed claim (LDOL-WC-1008) or when you have negotiated a l a m p sum settlement (LDOL-WC-1011). It m a y also be
requested at other tines by the OWCA. It is the employer's responsibility to complete this form a n d a copy must b e provided to the employee. Failure
to submit this form when required may result in a fine of up to $500.00 b e i n g assessed against the employer. T h e employer's i n s u r a n c e c a r r i e r m i g h t
also require this form. It is also presently accepted by OSHA in lieu of their form O S H A 101.
U P P E R R I G H T C O R N E R
" E M P L O Y E E SOCIAL SECURITY N U M B E R - Enter the injured employee's social security number. This is a nine digit n u m b e r a n d you should
e n t e r it as three digits, a dash, two digits, a dash, then four digits.
E M P L O Y E R U.L A C C O U N T N U M B E R - This is a six digit n u m b e r assigned by the Louisiana D e p a r t m e n t of L a b o r for the purpose of r e p o r t i n g
unemployment i n s u r a n c e taxes.
* E M P L O Y E R F E D E R A L IDENTIFICATION N U M B E R - This should be a nine digit n u m b e r . This is the n u m b e r used w h e n r e p o r t i n g federci
withholding a n d F I C A taxes. You m a y provide this n u m b e r or the U.L account number. One or the o t h e r is r e q u i r e d to process y o u r form.
PURPOSE O F R E P O R T - Check all that apply. Remember if either the employee or employer t h i n k the case is work-related this form is due. Check
Possible Dispute to indicate there is a possible disagreement.
BODY O F T H E R E P O R T
ITEM 1 - DATE O F T H E R E P O R T - This should be in MM/DD/YY format with slashes between the month, date a n d year. This field represents
the date t h a t the r e p o r t is being typed or completed.
" I T E M 2 - D A T E O F I N J U R Y - T h e date of the i n j u r y should be entered here. Also, enter the time of the i n j u r y a n d check A . M .or P.M.
ITEM 3 - N O R M A L STARTING T I M E - Again, this should be entered in s t a n d a r d 12 h o u r format, such t h a t one o'clock in the afternoon would
be entered 1:00 a n d the P.M. box checked.
* ITEM 4 - IF E M P L O Y E E BACK T O WORK~ GIVE DATE - If the employee has r e t u r n e d to work since the i n j u r y a n d has continued to work,
the date of the r e t u r n should be entered in block 4. If the employee has not r e t u r n e d to work, then you should e n t e r "still o u t " in this b l a n k
I T E M
5 -
A T S A M E W A G E - If the employee has returned, then Item 5 should be answered. If the employee is e a r n i n g as m u c h or more t h a n
the wages at the time of the injury, the " Y e s " block should be checked, l f t b e employee is e a r n i n g less t h a n the earnings at the time of injury, the
" N o " block should be checked.
I T E M
6 -
IF F A T A L INJURY, G I V E DATE O F D E A T H - If the employee died as a result of the accident o r occurrence at work, then the date
of d e a t h should be entered in the M M / D D / Y Y format. This is required if incident resulted in death.
I T E M 7 - T H E D A T E E M P L O Y E R K N E W O F I N J U R Y - The employer knew of the injury of illness w h e n it was b r o u g h t to the employer's
attention. The employer could be any supervisor or agent of the employer. The fact t h a t this r e p o r t is being typed indicates t h a t the employer knew
of the incident at some tim~ E n t e r the earliest date in MM/DD/YY format t h a t the employer knew of the i n j u r y or illness.
* I T E M
8 -
DATE DISABILITY BEGAN - Sometimes the employee does not become disabled until after the incident occurred. A t o t h e r times the
disability is immediate. In this block place the fwst date that the employee lost time from work as a result of the injury or illness. It should be entered
in MM/DD/YY format.
I T E M 9 - LAST F U L L DAY PAID D A T E - E n t e r the last day the employee was paid in full. If the disability b e g a n as a result of the employee
leaving work at the end of the work day, t h e n the last full day paid would be the day the i n j u r y occurred. If the employee was injured early in the
work day a n d was not p a i d for the full day, then the last full day paid would be the p r i o r work day. Use M M / D D / Y Y f o r m a t
* I T E M 10 - E M P L O Y E E : FIRST~ M I D D L E 1 LAST - E n t e r the employee's n a m e in the form of fwst name, middle n a m e or initial, last name.
* I T E M 11 - MALE~ F E M A L E - C h e c k the box indicating the gender of the injured employee.
I T E M 12 - E M P L O Y E E T E L E P H O N E N U M B E R (Include Area Code) - E n t e r the employee's telephone n u m b e r including the area code.
• ITEM 13 - C O M P L E T E A D D R E S S - This should be the mailing address of the employee a n d should include the street address, city, parish, state
a n d zip code. P a r i s h of employee's residence is required.
* I T E M 14 - P A R I S H O F I N J U R Y - E n t e r the n a m e of the parish in which the injury/iliness occurred.
I T E M 15 - D A T E O F H I R E - E n t e r date employee was hired by you. If b r e a k in employment greater t h a n 6 months, e n t e r the re-hire date.
* I T E M 16 - A G E A T I L L N E S S / I N J U R Y - E n t e r the employee's age on the day the incident occurred. If not known, e n t e r a p p r o x i m a t e age.

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