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Blank Oregon 801 Form

The Oregon Form 801 is a critical document used for filing workers' compensation claims in the state of Oregon. This form meets the record-keeping requirements set by OSHA and ensures that both workers and employers understand their rights and responsibilities regarding workplace injuries. Timely submission of this form is essential, as delays may lead to claim denials or penalties.

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The Oregon Form 801 is a crucial document in the realm of workers' compensation, designed to facilitate the reporting and processing of claims related to workplace injuries and occupational diseases. This form not only meets the record-keeping requirements set forth by OSHA but also outlines essential responsibilities for both workers and employers. For workers, it is vital to file a claim within 90 days of an injury or within one year of discovering an occupational disease, as failure to do so may lead to denial of the claim. Employers, on the other hand, are required to report any claims to their insurance company within five days of becoming aware of the incident. The form includes specific sections where workers provide detailed information about their injuries, including the nature of the injury, the body parts affected, and a thorough description of the accident. Employers must also complete sections that capture their business identification and the nature of the business, ensuring that all necessary information is documented for the insurance provider. Furthermore, the form emphasizes the importance of accurate reporting, as incomplete submissions can delay benefits and create complications in the claims process. By understanding the components and requirements of the Form 801, both workers and employers can navigate the workers' compensation system more effectively, ensuring that injured employees receive the support they need while maintaining compliance with state regulations.

Form Example

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:
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:
What is your illness or injury? What part of the body? Which side? (Example: Sprained right foot) Left Right
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)
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:
Work phone:
Occupation:
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.
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.
Worker
signature:
Completed by
(please print):
Date:
Employer
Complete the rest of this form and give a copy of the form to the worker. Even if the worker does not want to file a claim, keep 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:
By my signature, I acknowledge I am responsible for notifying my workers’ compensation insurance company within five days of knowledge of the claim.
I
understand I may not restrict the worker’s choice of or access to a health care provider. If I do, it could result in civil penalties under ORS 656.260.
Employer
signature:
Name and title
(please print):
Date:
440-8
01 (1/21/DCBS/WCD/WEB)
OSHA requirements:
Employers must report work-related fatalities and catastrophes to Oregon OSHA either in person or
by telephone within eight hours. In addition, employers must report any in-patient hospitalization, loss of an eye, and any
amputation or avulsion that results in bone or cartilage loss to Oregon OSHA within 24 hours. See OAR 437-001-0704. Call
800-922-2689 (toll-free), 503-378-3272, or Oregon Emergency Response, 800-452-0311 (toll-free), on nights and weekends.
801
↓ Oregon 801 PDF Form

Document Characteristics

Fact Name Description
OSHA Compliance The Oregon Form 801 meets the record-keeping requirements set forth by OSHA Form 101, ensuring that employers are compliant with safety regulations.
Filing Deadlines Workers must file a claim with their employer within 90 days of an injury or within one year of discovering an occupational disease to avoid denial of the claim.
Employer Responsibilities Employers are required to report any claims to their insurance company within five days of being notified of the claim to prevent delays in benefits and potential penalties.
Legal Authority This form is governed by the Oregon Revised Statutes, specifically ORS Chapter 656, which outlines the workers' compensation system in Oregon.
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