Employers First Report Of Injury Or Illness (For State Employees) {DWC-1S}

Mail this form to: STATE OFFICE OF RISK MANAGEMENT P. O. Box 13777 Austin, Texas 78711 CLAIM # Please read instruction sheet CAREFULLY, giving special attention to items marked with an asterisk (*). 1. Name (Last, First, M.I.) 2. Sex SORM CLAIM # EMPLOYERS FIRST REPORT OF INJURY OR ILLNESS 15. Date of Injury (m-d-y) 16. Time of Injury : am pm F 3. Social Security Number 4. Home Phone ( ) M 18. Nature of Injury* 17. Date Lost Time Began (m-d-y) - 5. Date of Birth (m-d-y) - 19. Part of Body Injured or Exposed* 6. Does the Employee Speak English? YES NO If No, Specify Language 20. How and Why Accident/Injury Occurred* 7. Employee Telephone # 8. Block no longer used 21. Was employee doing his/her YES regular job? NO 22. Worksite Location of Injury (stairs, dock, etc.)* 9. Mailing Address Street or P.O. Box 23. Address Where Injury or Exposure Occurred Name of business if incident occurred on a business site Zip Code County Street or P.O. Box County City State 10. Marital Status Married Widowed Separated Single Divorced City State Zip Code 11. Number of Dependent Children 12. Spouse's Name 24. Cause of Injury (fall, tool, machine, etc.)* 13. Doctor's Name Telephone # 25. List Witnesses (Name, Telephone # 14. Doctor's Mailing Address (Street or P.O.Box) 26. Return to work date (m-d-y) Zip Code 27. Did employee die? 28. Supervisor's Name 29. Date Reported (m-d-y) City State YES NO 30. Date of Hire (m-d-y) 31. Was employee hired or recruited in Texas? YES NO 32. Length of Service in Current Position Years Months ______ 33. Length of Service in Occupation Years Months ______ 34. State Payroll Classification Code 35. Occupation of Injured Worker 36. Rate of Pay at this Job Weekly $______ Hourly $ $ Monthly 37. Full Work Week is: Hours Days 38. Last Paycheck was: $_____________ 41. Name of Agency Claims Coordinator 39. Is employee an Owner, Partner, or Corporate Officer? YES NO 40. Name and Title of Person Completing Form 42. Agency Mailing Address and Telephone Number Street or P.O. Box City State 43. Agency Location Code Telephone ( ) ______ ______ ______ / _______ ______ _______ / ______ _______ _______ Zip Code Name of Location: ____________________________________________ 45. Primary North American Industrial Classification System 46. Specific NAICS Code 47. Comptroller Agency Code Sector Code (NAICS) (2 digits) 49. Policy Number 44. Federal Tax Identification Number 48. Workers' Compensation Insurance Company State Office of Risk Management 50. Did you request accident prevention services in past 12 months? YES NO If yes, did you receive them? YES NO 51. Signature and Title (READ INSTRUCTIONS ON INSTRUCTION SHEET BEFORE SIGNING) TXSTATEPOL001 52. Number of Hours of Sick/Annual Leave Credted to Employee or Date of Injury American LegalNet, Inc. www.USCourtForms.com DWC FORM-1S (Rev. 10/05) Page 1 DIVISION OF WORKERS' COMPENSATION DWC FORM-1S Instructions PLEASE COMPLETE ALL APPLICABLE FIELDS. Most fields are self-explanatory; however, the following items may require more attention: Item 4: If no home phone, please give a phone number where the employee can be reached. Item 7: Employees work phone number. Item 8: This information is no longer required. Item 13: This information should include the doctor's telephone number. Item 15: This should be the actual date of injury, or (for occupational diseases) the date the employee knew or should have known the condition was work-related. Item 17: This should be the first full day of lost-time from work. (Please note that the date of injury is not considered the first day of lost time.) Mark NLT or N/A if there is no lost time. Item 18: List the nature of the injury. Examples include: burn, cut, or sprain. Item 19: List specific body part, which side of body is affected, e.g., chin, right leg, left upper arm, etc. If more than one body part is affected, list each part. Item 20: Describe in detail. Use additional sheet of paper if necessary. Item 24: This should state the specific substance or exposure that directly inflicted the injury such as a tool, chemical (list the name of the chemical), or machine. Item 26: The date should be entered even if the employee has returned to work even for a portion of the day. If the employee has returned to work making less than his or her pre-injury wage, a DWC FORM-6 must also be submitted. Item 28: This is the employee's immediate supervisor. Please include a work telephone number. Item 29: This is the date the employee reported the injury to the employer as work related. Item 34: This 4-digit code corresponds to the primary occupation in which the employee was engaged at the time of the injury or exposure. This code is from the state payroll classification table and is available from the State Comptroller of Public Accounts. Item 43: This 9-digit code represents the location of the agency unit that employed the injured worker at the time of their injury or exposure. The first three digits will be 100 for state agencies or 200 for county entities. The second three digits are the agency code. The third three digits are the location code as established by each agency. Contact the SORM's Risk Assessment and Loss Prevention section for information about or changes to your agency location code(s). Item 44: This 9-digit code is assigned to each agency by the Internal Revenue Service for employment, tax, and reporting purposes. Item 45: This 2-digit code is assigned to each agency according to its primary business activity. For specific questions regarding your NAICS code, call your local Texas Workforce Commission (TWC). Item 46: This is a 3- or 4-digit code for the specific subsector of the business activity of the agency. Item 47: This is the state agency code number assigned by the State Comptroller of Public Accounts. Item 51: This must be the signature and title of the claims coordinator. If signed by someone other than the claims coordinator, he or she must list his or her title and state that it was signed for the claims coordinator. The date must also be included. Item 52: Enter the number of sick/annual leave hours credited to the employee as of the date of injury. Distribution: Fax a copy or mail the original to: State Office of Risk Management Mail a copy to the claimant. Retain a copy for your file. State Office of Risk Management P.O. Box 13777 Austin, TX 78711-3777 American LegalNet, Inc. www.USCourtForms.com DWC FORM-1S (Rev. 10/05) Page 2 DIVISION OF WORKERS' COMPENSATION