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Get DoL LS-202 2012

Date of This Report Form LS-202 Rev. Oct. 1998 This report is to be filed in duplicate with the District Director in the appropriate district office of the Office of Workers Compensation Programs and is required by 33 U.S.C. Employer s First Report of Injury or Occupational Illness U*S* Department of Labor Employment Standards Administration Office of Workers Compensation Programs See instructions on reverse - Leave items 1 and 2 blank OMB No* 1215-0031 1. OWCP No* 2. Carrier s No* 3. Date and Time of Accident Mo. Day Yr. 4. Name of Injured/Deceased Employee Type or print - first M. I. last Hour AM PM 5. Employee s Address No* street city state ZIP code Telephone 6. Injury is Reported Under the Following Act Mark one 7. Indicate Where Injury Occurred Longshore Act only Mark one Building Way F Marine Railway G Outer Continental Shelf Lands Act D Marine Terminal E Nonappropriated Fund Instrumentalities Act C Dry Dock Other Adjoining Area 9. Date of Birth M 10. Social Security No* Required by Law 11. Did Injury Cause Death No Yes - If yes skip to 16 Day or Shift of Accident 13. Date and Hour Employee First Lost Time Because of Injury 14. Did Employee Stop Work Immediately Yes to Work 17. Did Injury/Death Occur on Employer s Premises 18. Dept. in Which Employee Normally Works ed 20. Date and Hour Pay Stopped 21. Which Days Usually Worked Per Week Mark X days S M T W T 23. Wages or Earnings Include overtime allowances etc* a* b. Hourly Daily c* d. Weekly Yearly 16. Was Employee Doing Usual Work When Injured/Killed If no explain in Item 26 19. Occupation 22. Date Employer or Foreman First Knew of Accident. 24. Exact Place Where Accident Occurred See instructions on reverse. This item should specify area if accident was in maritime employment and occurred in area adjoining navigable waters. Pier/Wharf Defense Base Act Aboard Vessel or Over Navigable Waters Longshore and Harbor Workers Compensation Act B A 8. Sex 25. How was Knowledge of Accident or 26. Describe in full how the accident occurred Relate the events which resulted in the injury or occupational disease. Tell what the injured was doing at the time of the accident. Tell what happened and how it happened* Name any objects or substances involved and tell how they were involved* Give full details on all factors which led or contributed to the accident. Use additional sheet s if required and attach to this report 27. Nature of Injury Name part of body affected - fractured left leg bruised right thumb etc* If there was amputation of a member of the body describe. 28. Has Medical Attention Been Authorized 29. Enter Date of Authorization Name 30. Was First Treating Physician Chosen by Employee 31. Has Insurance Carrier Been Notified Address - Enter Number Street City State ZIP Code 32. Physician 33. Hospital 34. Insurance Carrier Federal Claims Unit 400 High Street SE Salem OR 97312-1000 35. Employer 36. Nature of Employer s Business 38. Official Title of Person Signing This Report 37. Signature of Person Authorized to Sign for Employer 39.

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