Insert self-insured employer and insurer name, address, phone number, and service company, if any.	Report of Job Injury or Illness Workers’ compensation claim
Worker To make a claim for a work-related injury or illness, fill out the worker portion of this form and give it to your employer. If you do not intend to file a workers’ compensation claim with the insurance company, do not sign the signature line. Your employer will give you a copy.
Date of injury or illness:	Date you left work:	Time you began work on day of injury:	a.m. p.m.	Regularly scheduled days off: M T W T F S S	Dept Use:
Emp
Time of injury or illness:	a.m. p.m.	Time you left work:	a.m. p.m.	Check here if you have more than one job:
Ins
What is your illness or injury? What part of the body? Which side? (Example: Sprained right foot) Left Right	Occ
Nat
What caused it? What were you doing? Include vehicle, machinery, or tool used. (Example: Fell 10 feet when climbing an extension ladder carrying a 40-pound box of roofing materials)	Part
Ev
Src
2src
Information ABOVE this line; date of death, if death occurred; and Oregon OSHA case log number must be released to an authorized worker representative upon request.
Your legal name:	Language preference:	Birthdate:	Gender: M F
Your mailing address:	Home phone:
Social Security no. (see Form 3283):	Occupation:	Work phone:
Names of witnesses:
Name and phone number of health insurance company:	Name and address of health care provider who treated you for the injury or illness you are now reporting:
Were you hospitalized overnight? Yes No
Were you treated in the emergency room? Yes No
By my signature, I am making a claim for workers’ compensation benefits. The above information is true to the best of my knowledge and belief. I authorize health care providers and other custodians of claim records to release relevant medical records to the workers’ compensation insurer, self-insured employer, claim administrator, and the Oregon Department of Consumer and Business Services. Notice: Relevant medical records include records of prior treatment for the same conditions or of injuries to the same area of the body. A HIPAA authorization is not required (45 CFR 164.512(I)). Release of HIV/AIDS records, certain drug and alcohol treatment records, and other records protected by state and federal law requires separate authorization.
Worker signature:	Completed by (please print):	Date:
Employer Complete the rest of this form and give a copy of the form to the worker. Notify your workers’ compensation insurance company within five days of knowledge of the claim. Even if the worker does not wish to file a claim, maintain a copy of this form.
Employer legal business name:	Phone:	FEIN:
If worker leasing company, list client business name:	Client FEIN:
Address of principal place of business (not P.O. Box):	Insurance policy no.:
Street address from which worker is/was supervised:	ZIP:	Nature of business in which worker is/was supervised:
Address where event occurred:
Was injury caused by failure of a machine or product, or by a person other than the injured worker? Yes No
Were other workers injured? Yes No	OSHA 300 log case no:
Date employer knew of claim:	Date worker returned to work:	Worker’s weekly wage: $	Date worker hired:	If fatal, date of death:
Employer signature:	Name and title (please print):	Date:
440-801 (01/10/DCBS/WCD/WEB)	OSHA requirements: On-the-job fatalities and catastrophes must be reported to Oregon OSHA within eight hours. Report any accident that results in overnight hospitalization within 24 hours to Oregon OSHA. Call 800-922-2689, 503-378-3272, or Oregon Emergency Response, 800-452-0311, on nights and weekends.	801