Instructions For Completing The Employer Report Of Injury/illness (Ldol-Wc-1007) (Page 2 of 2) in pdf

" I T E M 17 - O C C U P A T I O N - Give a clear description of the employee's occupation. T r y to avoid j a r g o n t h a t would b e difficu|t ~e ~ , t ~ a n d .

Do not a b b r e v i a t e with single letters; such as F.S.W. Instead, p u t Food Service Worker.

I T E M 18 - D E P A R T M E N T O R DIVISION R E G U L A R L Y E M P L O Y E D - The d e p a r t m e n t or division regularly employed will help those

investigating the accident in large plants to fmd the place where the accident occurred a n d the people who m a y know a b o u t t h e accident.

ITEM 19 - P L A C E O F INJURY - E M P L O Y E R ' S P R E M I S E S : YES O R NO - Indicate w h e t h e r the i n j u r y occurred on the employer's premises.

A "Yes" indicates t h a t the i n j u r y took place on the employer's premises.

ITEM 20 - IF " N O " - GIVE CITY & S T A T E - I f the " N o " block was checked, list the exact location of the injury including city, a n d state.

* ITEM 21 - W H A T W O R K A C T I V I T Y W A S T H E E M P L O Y E E DOING.9 - Describe events fully giving the weight, size a n d s h a p e of materials

or equipment involved. Indicate if employee was following correct w o r k procedures. Specify if this is a n occupational i n j u r y o r illness.

Example 1 - Employee i n j u r e d while lifting numerous 30 lb. boxes into truck a t loading d o c k Dollies are

provided for this task b u t employee refused to use them.

Example 2 - Employee i n j u r e d while climbing a 10 foot l a d d e r a n d c a r r y i n g 20 p o u n d s of roofmg materials a n d

cutting tools.

Example 3 - Employee became ill after s p r a y i n g insecticide from a h a n d sprayer. Respirator was p r o v i d e d b u t

not used.

ITEM 22 - W H A T CAUSED I N C I D E N T T O H A P P E N . 9 - Describe fully the events which resulted in i n j u r y o r disease. Tell w h a t h a p p e n e d a n d

how it happened. Name any objects or substances involved a n d tell how they were involved. Give full details o n all factors which led or contributed

to injury o r illness. This should be a n a r r a t i v e explaining specifically how the incident took place.

Example 1 - Employee complained of b a c k pain after lifting boxes for I week (approximately SO boxes p e r day).

Example 2 - L a d d e r slipped on wet g r o u n d a n d employee fell 10 feet.

Example 3 - Gasket on sprayer broke a n d employee's eyes a n d m o u t h were Idled with Demeton.

* ITEM 23 - PART O F BODY AND N A T U R E O F I N J U R Y / I L L N E S S - This b l a n k identifies the part(s) of body involved a n d the n a t u r e of the

injury a n d illness to t h a t body part(s). Be sure to include all parts of body affected.

Example 1: S p r a i n to lower back, s t r a i n to u p p e r b a c k

Example 2: F r a c t u r e d r i g h t ankle, fractured r i g h t femur, a m p u t a t e d right index f m g e r at 2 n d joint,

sustained multiple bruises a n d contusions over entire body, strained lower b a c k

Example 3: Redness a n d itching of the eyes, vomiting, abdominal cramps, difficulty b r e a t h i n g a n d

convulsions~

ITEM 24 - IF OCCUPATIONAL DISEASE - GIVE D A T E D I A G N O S E D - Complete this block for all occupational disease cases by e n t e r i n g the

date a physician diagnosed the disease/illness as occupational.

ITEM 25 - PHYSICIAN A N D A D D R E S S - List the physician who treated the employee initially. Give t h e i r address.

I T E M 26 - H O S P I T A L N A M E AND A D D R E S S - If admitted for treatment, give the n a m e a n d address of h o s p i t a l

* ITEM 27 - E M P L O Y E R N A M E - E n t e r the n a m e of the employer as it is carried on the employer's i n s u r a n c e policy.

* ITEM 28 - P E R S O N C O M P L E T I N G T H I S R E P O R T - E n t e r y o u r name.

" ITEM 29 - E M P L O Y E R A D D R E S S - E n t e r the address of the employer including the street address, city, state a n d zip.

* ITEM 30 - E M P L O Y E R ' S T E L E P H O N E N U M B E R - E n t e r the telephone n u m b e r at work where you c a n be reached. I f t h e r e is a n extension

include t h a t as well as the a r e a code.

ITEM 31- E M P L O Y E R ' S M A I L I N G A D D R E S S - IF D I F F E R E N T F R O M A B O V E - I f the employer h a s a mailing address different from the

address listed in Item 29 e n t e r it in this b l o c k

ITEM 32

N A T U R E O F BUSINESS - E n t e r the n a t u r e of the business of the employer. This should be as specific as possible. F o r example use

auto p a r t m a n u f a c t u r i n g instead of p a r t m a n u f a c t u r i n g , or Single family residential construction instead of construction.

NAME O F W O R K E R ' S C O M P E N S A T I O N INSURER - E n t e r Employer's Workers' Compensation c a r r i e r ' s n a m e a n d address. If self-insured

write "serf-insured". If a m e m b e r of a g r o u p self insured plan, n a m e t h a t group a n d not the a d j u s t i n g c o m p a n y or claims administrator. Give the

phone n u m b e r a n d area code of t h e i r claims department.

P A G E 2 - T u r n to the b a c k of the form, then r e a d a n d complete the LDOL-WC-102S.ER or Employer Certificate of Compliance.

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