Report of Job Injury or Illness


If you would like to fill out the paper version of this form, please request it via email at claimswc@cisoregon.org or call 503-763-3875.

Your Information

First Name:  

Last Name:  

Middle Name:  

Job Title:  

Home Mailing Address:  

City:  

State:  

Zip:    

Home Phone:    

Work Phone:    

Birth Date:    

Gender:  

SSN:    

Preferred Language:


Your Illness/Injury

Date of Injury:    

Time of Injury:  

Which part of the body?  

Which side of the body?  

Have you previously injured or sought treatment for this body part?

 

What caused it? What were you doing?  

Name of witnesses:

Name of physician or health-care professional who treated you for the injury or illness you are now reporting:

 

If medical treatment was given away from the worksite, provide name and address of facility

Were you hospitalized overnight as an inpatient?  

Were you treated in the emergency room?  

Your Work

Employer:  
Department:  

Date you left work:    

Time you left work:



Shift on day of injury:

From:  To:    

Regularly scheduled days off:



Are you employed by more than one employer:

 

Do you have a preferred worker card?

 


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.

I understand I have a right to see a health care provider of my choice subject to certain restrictions under ORS 656.260 and ORS 656.325.

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