Employee Workplace Injury Reporting Instructions
Employer’s Report of Occupational Injury or Disease (Injury Report)
• The two-page Injury Report form must be completed and forwarded to the Human
Resources Office, Reeder Hall, 2nd Floor, within five (5) days of the date of injury.
Injury Reports can be faxed to (814) 732-2885. Instructions on completing the Injury
Report are provided in Employer’s Report of Occupational Injury or Disease (Injury Report)
Completion Instructions section provided below.
• See Appendix B for sample form.
Witness Statement
• Complete the Witness Statement providing a detailed account of the incident.
• Complete a separate statement for each witness.
Workers’ Compensation Employee Notification and Information Forms
• This is a two-page form; both pages must be signed and returned with the Injury
Report.
Physical Capacities Checklist Form
• This form should be given to the provider to complete in the event that the treating
provider recommends modified or light duty. The form should be returned to the
Human Resources Office. Forms can be faxed to (814) 732-2885. A copy will be
provided to your supervisor.
Important Information
Medical Treatment for Your Workplace Injury
• If you need medical treatment, you must be treated by a Panel Physician for the first
90 days of treatment. Payment for services provided by a non-panel provider
during the first 90-day period will be the employees’ responsibility unless a
referral is received from a panel provider.
Claim Number
• A claim number cannot be assigned until an Injury Report is received in the Human
Resources Office. The employee must contact the Human Resources Office to receive
their claim number. When receiving treatment for an injury, the employee will need to
give their claim number to the provider. All medical claims/forms received from the
medical provider must be returned to the Human Resources Office. The Human
Resources staff will then forward all related materials to Inservco, PASSHE’s third party
administrator for workers’ compensation claims.
QUESTIONS
Questions regarding Injury Reports and Workers’ Compensation issues should be directed to
the Human Resources Office, Reeder Hall, 2nd Floor, (814) 732-2703.
Human Resources & Faculty Relations
Rev. 11.01.2010
Employer’s Report of Occupational Injury or Disease
(Injury Report) Completion Instructions
General Instructions:
• All Auxiliary Services, i.e., Chartwell’s and/or University Services Inc., employees must contact their immediate
supervisor for work-related injury reporting procedures.
• The Employer’s Report of Occupational Injury or Disease (Injury Report) must be completed in the event that an
employee is injured as the result of a workplace accident. Please complete in blue or black ink or typewritten.
• Injury reports should be returned to the Human Resources Office within five (5) days of the date of injury. A claim
number cannot be assigned until the original report is returned. IMPORTANT: Do NOT mail the form to the
Department of Labor and Industry as directed on the front page, lower left hand corner of the form. Injury reports
are electronically forwarded by the Human Resources Office to Inservco, PASSHE’s third party administrator for
worker’s compensation claims.
• If employee needs to seek medical treatment for their work injury, they must treat with a panel provider for the first
90 days of treatment. Please see the Panel Physician/Provider list. If an employee is referred off panel by a panel
physician, they need to contact the Human Resources Office prior to seeing the non-panel physician.
• Questions should be addressed to the Human Resources Office at (814) 732-2703.
Completing the Injury Report:
• The Injury Report is two pages - complete both pages
• Enter all dates as MMDDYYYY
• Enter all times as HHMM, checking the AM or PM box, as appropriate. Do Not use military time.
• For the type of injury, part of body affected, and cause of injury codes sections; select the most accurate
description from the code tables (See Appendix A); fill in the corresponding numerical code and the description.
Information Boxes:
1. Employee Information:
• Enter the employee’s social security number (upper right-hand corner on page 1)
• Enter the date of injury (upper right-hand corner on page 1)
• Enter the employee’s first name, last name, home street address (city, sate, zip, county), and phone number
• Enter the employee’s gender, marital status, and date of birth
• Number of dependents – Leave blank
• Enter the employee’s job title
• Enter employee’s work status
2. Leave the following items blank:
• NCCI Class Code
• SIC-Code
• Employer FEIN
•
•
•
(Employer) Phone Number
(Employer) County
NAICS Code
•
Full Pay for Date of Injury
3. Time Employee Began Work – Enter the time the employee began work the day of the injury
4. Time of Occurrence – Enter the time the injury occurred
5. Last Day Worked – Enter the date of injury
6. Date Disability Began - Leave blank if injury is medical only and does not involve lost time from work
•
•
Date Returned to Work - If injury resulted in disability (employee absent from work), complete this box with the
date of the last day worked. A medical provider’s certificate stating that employee is disabled due to work injury
must be provided in order for employee to be eligible for compensation benefits. There is a waiting period for
compensation benefits.
If injury did not result in a disability (no work missed), leave blank.
Human Resources & Faculty Relations
Rev. 11.01.2010
7. Date Employer Notified – Enter the date that the supervisor or Human Resources Office was informed that an injury
occurred
8. Date Returned to Work – Enter the date the employee returned to work
9. Date of Hire – Enter the employee’s date of hire
10. Injury Information (See Appendix A):
•
•
•
•
•
•
•
•
•
•
•
•
Type of Injury Code – Select the appropriate numerical code from Type of Injury Codes table
Part of Body Affected Code – Select the appropriate numerical code from Part of Body Affected Codes table
Cause of Injury Code – Select the appropriate numerical code from Cause of Injury Codes table
Type of Injury or Illness – Enter the description corresponding with the Type of Injury Code entered previously
Parts of Body Affected – Enter the description corresponding with the Part of Body Affected Code entered
previously
Cause of Injury – Enter the description corresponding with the Cause of Injury Code entered previously
Did Injury or Illness Occur on Employer’s Premises? Check the appropriate box
If Out of State, Specify State of Injury – Leave blank if injury occurred in Pennsylvania
Were Safeguards or Safety Equipment Provided - Check appropriate box or leave blank if not applicable
Were Safeguards or Safety Equipment Used - Check appropriate box or leave blank if not applicable
All Equipment, Materials, or Chemicals Employee was Using when Accident or Illness Exposure Occurred
– List any equipment, material or chemicals that were being used when the injury occurred or leave blank if not
applicable
How Injury or Illness/Abnormal Health Condition Occurred. Describe the Sequence of Events and Include
Any Objects or Substances Directly Responsible – Describe, in detail, how the injury occurred. Attach an
additional sheet if necessary
11. If Fatal, Give Date of Death – Write in date of death. NOTE: If a workplace accident results in the death of an
employee, the EUP Benefits Manager MUST be notified IMMEDIATELY.
12. Initial Treatment – Check appropriate box(es)
13. Provider Information:
• Physician/Health Care Provider – Fill in the name and address of treating provider or leave blank if not
applicable
• Hospital Name – Enter the name and address of treating hospital or leave blank if not applicable
14. Leave the following items blank:
• Policy/Self Insured Number
•
Policy Period From
•
Policy Period To
15. Witness Information (Attach a separate sheet if more than one witness):
• Witness First Name: Enter the witness’ first name
• Witness Last Name: Enter the witness’ last name
• Witness Phone Number: Enter the witness’ phone number
16. Person Completing This Form: Enter the name, title and phone number of person completing the Injury Report
(supervisor or employee)
17. Insurance Carrier or Third Party Administrator (If Self-Insured): Leave blank
18. Date Prepared: Enter the date this report was completed – may be different from the date of injury
Human Resources & Faculty Relations
Rev. 11.01.2010
APPENDIX A
Type of Injury Codes
Code
1
2
3
4
7
10
13
16
19
22
25
28
30
31
32
34
36
37
40
41
42
Description
No Physical Injury
Amputation
Angina Pectoris – Stroke
Burn
Concussion
Contusion
Crushing
Dislocation
Electric Shock
Enucleation
Foreign Body
Fracture
Freezing
Hearing Loss or
Impairment
Heat Prostration
Hernia
Infection
Inflammation
Laceration
Myocardial Infarction
(Heart Attack)
Poisoning – General (Not
OD or Cumulative Injury)
Code
43
46
47
49
52
53
Description
Puncture
Rupture
Severance
Sprain
Strain
Syncope (Unconscious,
Faint)
54
Asphyxiation
55
Vascular
58
Vision Loss
59
All Other Specific Injuries,
No Other Code (NOC)
Occupational Disease or
Cumulative Injury
60
Dust Disease, NOC (All
Other Pneumoconiosis)
61
Asbestosis
62
Black Lung
63
Byssinosis
64
Silicosis
65
Respiratory Disorders
(Gases, Fumes,
Chemicals, Etc.)
66
Poisoning – Chemical
Code
67
68
69
70
71
72
73
74
75
76
77
78
79
80
90
91
Description
(Other than metals)
Poisoning – Metal
Dermatitis
Mental Disorder
Radiation (welding/flash)
All Other Occupational
Disease Injury, NOC
Loss of Hearing
Contagious Disease
Cancer
AIDS
VDT-Related Disease
(visual terminal display)
Mental Stress
Carpel Tunnel Syndrome
Hepatitis C
All Other Cumulative
Injuries, NOC
Multiple Injuries
Multiple Physical Injuries
Only
Multiple Injuries Including
Both Physical and
Psychological
Part of Body Affected Codes
Code
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
30
31
32
Description
Head
Multiple Head Injury
Skull
Brain
Ear(s)
Eye(s)
Nose
Teeth
Mouth
Head – Soft Tissue
Facial Bones
Neck
Neck – Multiple Injury
Vertebrae
Neck – Disc
Neck – Spinal Cord
Larynx
Neck – Soft Tissue
Trachea
Upper Extremities
Multiple Upper Extremities
Upper Arm (including
Clavicle and Scapula)
Elbow
Human Resources & Faculty Relations
Code
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
60
61
Description
Lower Arm
Wrist
Hand
Finger(s)
Thumb
Shoulder(s)
Wrist(s) and Hand(s)
Trunk
Multiple Trunk
Upper Back Area
(Thoracic Area)
Low Back Area (including
Lumbar and LumboSacral)
Back Disc
Chest (including Ribs,
Sternum and Soft Tissue)
Sacrum and Coccyx
Pelvis
Back – Spinal Cord
Internal Organs
Heart
Lungs
Abdomen including Groin
Code
62
63
50
51
52
53
54
55
56
57
58
64
65
66
90
91
Description
Buttocks
Lumbar and/or Sacral
Vertebrae (Vertebrae
NOC Trunk)
Lower Extremities
Multiple Lower Extremities
Hip
Upper Leg
Knee
Lower Leg
Ankle
Foot
Toe(s)
Great Toe
Multiple Body Parts
Artificial Appliance
Insufficient Info to
Properly Identify –
Unclassified
No Physical Injury
Multiple Body Parts
Body Systems and
Multiple Body Systems
Rev. 11.01.2010
Cause of Injury Codes
Code Description
Burn or Scald – Heat or Cold
Exposure
1
Burn – Acid Chemicals
2
Burn – Contact with
Object
3
Burn – Temperature
Extremes
4
Burn – Fire or Flame
5
Burn – Steam or Hot
Fluids
6
Burn – Dust, Gases,
Fumes, Vapor
7
Burn – Welding
Operations
8
Burn – Radiation
9
Burn – Miscellaneous
11
Burn – Cold Objects or
Substances
14
Burn – Abnormal Air
Pressure
84
Electrical Current
Caught In or Between
10
Caught In – Machinery
12
Caught In – Object
Handled
13
Caught In or Between –
Miscellaneous
20
Caught In – Collapsing
Materials (Slides of Earth)
Cut, Puncture, Scrape Injured By
15
Cut injured by – broken
glass
16
Cut injured by – hand tool
use
17
Cut injured by – object
being lifted or handled
18
Cut injured by – power
tool
19
Cut injured by –
miscellaneous
Fall or Slip Injury
25
Fall or Slip – from
different level
26
Fall or Slip – from ladder
27
Fall or Slip – from liquid
28
Fall or Slip – into
openings
29
Fall or Slip – same level
30
Slipped, did not fall
Human Resources & Faculty Relations
Code
31
Description
Fall or Slip – fall, slip, trip
NOC
32
Fall or Slip – on ice or
snow
33
Fall or Slip – on stairs
Motor Vehicle
40
Motor Vehicle – crash of
water vehicle
41
Motor Vehicle – crash of
rail vehicle
45
Mother Vehicle – collision
or sideswipe with another
vehicle
46
Motor Vehicle – collision
with a fixed object
47
Motor Vehicle – crash of
airplane
48
Motor Vehicle – vehicle
upset
50
Motor Vehicle –
miscellaneous
Strain or Injury By
52
Strain Injury by –
Continual Noise
53
Strain Injury by – Twisting
54
Strain Injury by – Jumping
55
Strain Injury by – Holding
or Carrying
56
Strain Injury by – Lifting
57
Strain Injury by – Pushing
or Pulling
58
Strain Injury by –
Reaching
59
Strain Injury by – Using
Tool or Machinery
60
Strain Injury by Miscellaneous
61
Strain Injury by – Wielding
or Throwing
97
Strain Injury by –
Repetitive Motion
Striking Against or Stepping On
65
Stepping On/Striking –
Moving Parts of Machine
66
Stepping On/Striking –
Object Being Lifted or
Handled
67
Stepping On/Striking –
Sanding, Scraping,
Code
Description
Cleaning Operations
68
Stepping On/Striking –
Stationary Object
69
Stepping On/Striking –
Sharp Object
70
Stepping On/Striking –
Miscellaneous
Struck or Injured By
74
Struck/Injured by – Fellow
Worker
75
Stuck/Injured by – Falling
or Flying Object
76
Struck/Injured by – Hand
Tool or Machine in use
77
Struck/Injured by – Motor
Vehicle
Struck or Injured By (cont’d)
78
Struck/Injured by –
Moving Parts of Machine
79
Struck/Injured by – Object
being lifted or handled
80
Struck/Injured by – Object
handled by others
81
Struck/Injured by Miscellaneous
85
Struck/Injured by –
Animal/Insect
86
Struck/Injured by –
Explosion or Flare Back
Rubbed or Abraided By
94
Rubbed or Abraided by
repetitive motion
95
Rubbed or Abraided NOC
Miscellaneous Causes
82
Misc – Absorption,
Ingestion or Inhalation,
NOC
87
Misc – Foreign
Matter/Body in Eye(s)
89
Misc – Person in Act of
Crime
90
Misc – Other than
Physical Cause of Injury
98
Misc – Cumulative, NOC
99
Misc – Other,
Miscellaneous, NOC
Rev. 11.01.2010
APPENDIX B
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF LABOR AND INDUSTRY
BUREAU OF WORKERS’ COMPENSATION
1171 S. CAMERON STREET, ROOM 103
HARRISBURG, PA 17104-2501
(TOLL FREE) 800-482-2383
TTY (TOLL FREE) 800-362-4228
1
1
EMPLOYER’S REPORT
OF OCCUPATIONAL
INJURY OR DISEASE
EMPLOYEE SOCIAL SECURITY NUMBER
DATE OF INJURY
DO NOT MAIL -- RETURN TO
HUMAN RESOURCES,
REEDER HALL 2ND FLOOR.
EMPLOYEE FIRST NAME
-
-
-
MONTH
DAY
YEAR
EMPLOYEE LAST NAME
STREET ADDRESS
CITY
STATE
ZIP CODE
COUNTY
PHONE NUMBER
EMPLOYEE:
MALE
MARRIED
NUMBER OF DEPENDENTS
FEMALE
SINGLE
-
DATE OF BIRTH
-
-
MONTH
DAY
YEAR
OCCUPATION OR JOB TITLE
2
1
NCCI CLASS CODE (IF KNOWN)
EMPLOYMENT STATUS
FT = Full-time
PT = Part-time
SL = Seasonal
VO = Volunteer
ZZ = Other
EMPLOYER
E
D I
N
B O
R O
U
N I
V E
R
S I
T Y
M E
A D
V I
L L
E
S
T R
E E
B O
R O
O
F
P
A
STREET ADDRESS
2 2
1 9
CITY
E
STATE
D I
N
SIC CODE
EMPLOYER FEIN
4
-
TIME EMPLOYEE BEGAN WORK
3
YES
:
NO
6
LAST DAY WORKED
MONTH
4
-
MONTH
8
DAY
DATE RETURNED TO WORK
-
-
MONTH
DAY
YEAR
MONTH
N
YEAR
9
DATE OF HIRE
DAY
CONTACT FIRST NAME
A Y
PM
DATE DISABILITY BEGAN
YEAR
AM
:
PM
DAY
TIME OF OCCURRENCE
AM
DATE EMPLOYER NOTIFIED
YEAR
MONTH
DAY
A T
T
E
8 1
E R
S O
4 - 7 3
2 - 2
N
NOTICE: Report should be clearly completed, (preferably typed)
and original mailed to the Bureau at the address in the upper left
corner and a copy to employee and insurer.
LIBC-344 REV 1-01
YEAR
CONTACT PHONE NUMBER
CONTACT LAST NAME
P
4-
NAICS CODE
FULL PAY FOR DAY OF INJURY?
W
1 6 4
PHONE NUMBER
COUNTY
7
ZIP CODE
P A
-
5
T
(OVER)
DO NOT MAIL -- RETURN TO
HUMAN RESOURCES,
REEDER HALL 2ND FLOOR.
7 0
3
10
LIBC 344
TYPE OF INJURY CODE
PART OF BODY AFFECTED CODE
CAUSE OF INJURY CODE (ENTER CODES, IF KNOWN)
TYPE OF INJURY OR ILLNESS
PARTS OF BODY AFFECTED
CAUSE OF INJURY
DID INJURY OR ILLNESS OCCUR
ON EMPLOYER’S PREMISES?
YES
IF OUT OF STATE, SPECIFY
STATE OF INJURY
NO
WERE SAFEGUARDS OR SAFETY
EQUIPMENT PROVIDED?
YES
WERE SAFEGUARDS OR SAFETY
EQUIPMENT USED?
YES
NO
NO
ALL EQUIPMENT, MATERIALS, OR CHEMICALS EMPLOYEE WAS USING WHEN ACCIDENT OR ILLNESS EXPOSURE OCCURRED
HOW INJURY OR ILLNESS/ABNORMAL HEALTH CONDITION OCCURRED. DESCRIBE THE SEQUENCE OF EVENTS AND INCLUDE ANY OBJECTS OR SUBSTANCES DIRECTLY RESPONSIBLE.
11
12
INITIAL TREATMENT:
IF FATAL, GIVE DATE OF DEATH
13
MONTH
NO MEDICAL TREATMENT
DAY
MINOR BY EMPLOYEE
YEAR
CLINIC / HOSPITAL
PHYSICIAN/HEALTH CARE PROVIDER
PANEL PHYSICIAN
FIRST NAME:
LAST NAME:
EMPLOYEE PHYSICIAN
STREET
EMERGENCY CARE
CITY
STATE
HOSPITALIZED MORE THAN 24 HOURS
ZIP
POLICY PERIOD FROM:
HOSPITAL NAME:
-
14
MONTH
STREET
CITY
15
STATE
14
DAY
YEAR
POLICY PERIOD TO:
ZIP
-
POLICY/SELF INSURED NUMBER:
MONTH
WITNESS FIRST NAME
DAY
YEAR
WITNESS PHONE NUMBER
-
-
WITNESS LAST NAME
16
PERSON COMPLETING THIS FORM:
INSURANCE CARRIER OR THIRD PARTY ADMINISTRATOR (IF SELF-INSURED)
NAME:
NAME:
TITLE:
STREET
PHONE:
STATE
CITY
18
FEIN:
BUREAU CODE:
DATE PREPARED
MONTH
DAY
YEAR
Any individual filing misleading or incomplete information knowingly and with intent to
defraud is in violation of Section 1102 of the Pennsylvania Workers’ Compensation Act
and may also be subject to criminal and civil penalties through Pennsylvania Act 165.
17
ZIP