Blank Drsxxx Template

The Drsxxx form, also known as the First Report of an Injury, Occupational Disease or Death, is used to document an employee's work-related injury or illness. It is essential for filing a claim with the Ohio Bureau of Workers' Compensation. Completing this form accurately and promptly helps streamline the claims process.

For further assistance, fill out the form by clicking the button below.

Article Guide

The Drsxxx form, officially known as the First Report of an Injury, Occupational Disease or Death, is a critical document for reporting work-related incidents in Ohio. When filling out this form, it's essential to complete all three sections as thoroughly as possible. Doing so will expedite the claim determination process. If the injured worker is at their first medical visit, they can hand the form to the healthcare provider to complete the treatment information. After the form is completed, it must be sent to the employer or their managed care organization (MCO) through mail, fax, or delivery. If the injured worker does not know their employer’s MCO, assistance is available through the Bureau of Workers' Compensation (BWC) at 1-800-644-6292. For those employed by a self-insuring employer, specific steps must be followed to ensure proper submission. Completing this form accurately and promptly is vital. The information contained guides the BWC in administering claims and determining appropriate benefits. Assistance is readily available during business hours, ensuring that injured workers receive the necessary help in completing this form. Delays can occur, particularly with self-insured employers, so timely action is important.

Form Sample

First Report of an Injury,

Occupational Disease or Death

This form can be completed and submitted online at

www.bwc.ohio.gov

Report your injury by completing all three sections of this form

1Complete as much of all three sections of this form as possible to reduce the time necessary in determining the claim. If this form is completed by the injured worker at the irst visit to a medical provider, the injured worker may give the FROI to the provider to complete the treatment information section.The provider can then submit the FROI to the MCO.

2Deliver, mail or fax the completed document to your employer or your employer's managed care organization (MCO).

3If you do not know your employer's MCO, contact BWC at 1-800-644-6292 and follow the prompts, or use the MCO on BWC's Web site at www. bwc.ohio.gov.

4If you are unable to determine your MCO, mail or fax this form to the BWC customer service ofice closest to your home. For information on your local customer service ofice, please visit www.bwc.ohio.gov., or call 1-800-644-6292.

Injured workers employed by a self-insuring employer

•Complete this form and give to your employer.

•Your employer should be able to tell you if he or she is a self-insuring employer.

•If your employer is self-insuring and you ile this information with BWC, processing delays may occur.

For assistance in completing this form, call your BWC customer service ofﬁce Monday through Friday, 8 a.m. – 5 p.m.

Cambridge	Dayton	Mansﬁeld
61501 Southgate Road	3401 Park Center Drive, Suite 100	240 Tappan Drive, N., Suite A
Cambridge, OH 43725-9114	Dayton, OH 45414-2577	Ontario, OH 44906-1366
Phone: 740-435-4200	Phone: 937-264-5000	Phone: 419-747-4090
Fax: 866-281-9351	Fax: 866-281-9356	Fax: 866-336-8350

Canton	Garﬁeld Heights	Portsmouth
339 E. Maple St., Suite 200	4800 E. 131 St., Suite A	1005 Fourth St.
North Canton, OH 44720-2593	Garﬁeld Heights, OH 44105-7132	Portsmouth, OH 45662-4315
Phone: 330-438-0638	Phone: 216-584-0100	Phone: 740-353-2187
Toll free: 800-713-0991	Toll free: 800-224-6446	Fax: 866-336-8353
Fax: 866-281-9352	Fax: 866-457-0590
		Toledo
Cleveland	Governor’s Hill	P.O. Box 794
615 Superior Ave. W.	8650 Governor’s Hill Drive	1 Government Center, Suite 1136
Cleveland, OH 44113-1889	Cincinnati, OH 45249-1369	Toledo, OH 43697-0794
Phone: 216-787-3050	Phone: 513-583-4400	Phone: 419-245-2700
Toll free: 800-821-7075	Fax: 866-281-9357	Fax: 866-457-0594
Fax: 866-336-8345
	Lima	Youngstown
Columbus	2025 E. Fourth St.	242 Federal Plaza, W., Suite 200
30 W. Spring St.	Lima, OH 45804-4101	Youngstown, OH 44503-1206
Columbus, OH 43215-2256	Phone: 419-227-3127	Phone: 330-797-5500
Phone: 614-728-5416	Toll free: 888-419-3127	Toll free: 800-551-6446
Fax: 866-336-8352	Fax: 866-336-8346	Fax: 866-457-0596

Completion

Last name, ﬁrst name, middle initial

Social Security number

Marital status

Date of birth

Single

instructions

info.

Home mailing address

Sex

Married

Number of dependents

Male

Female

Divorced

(continued)

City

State

9-digit ZIP code

Country if different from USA

Separated

Department name

Widowed

injury/disease/death

Wage rate

Hour

Month

Week

What days of the week do you usually work?

Regular work hours

$________________ Per: 3

Year

Other _________________

Sun

Mon

Tues

Wed

Thur

Fri

Sat

From ____ To ____ 4

Have you been offered or do you expect to receive payment or wages for this claim from anyone other than the Ohio Bureau

Occupation or job title

of Workers' Compensation? YES

NO If yes, please explain.

Employer name

Mailing address (number and street, city or town, state, ZIP code and county)

Location, if different from mailing address

Was place of accident or exposure on employer's premises? Yes

If no, give accident location, street address, city, state and ZIP code.

Date of injury/disease

Time of injury

If fatal, give date of death

Time employee began

Date last worked

Date returned to work

__________

a.m.

p.m.

work

a.m.

p.m.

Date hired

State where hired

Date employer notiﬁed 12

State where supervised

and

Description of accident (Describe the sequence of events that directly

Type of injury/disease and part(s) of body affected

injured the employee, or caused the disease or death)

(for example: sprain of lower left back, etc.)

worker

and beneﬁts under Ohio's workers’ compensation laws for my claim, and I waive and release my right to ﬁle for and receive compensation and beneﬁts under the laws of any other state for this claim. I request

Injured

payment for compensation and/or medical beneﬁts as allowable, and authorize direct payment to my medical providers. I permit and authorize any provider who attends, treats or examines me, the Ohio State Board

of Pharmacy, the Ohio Department of Job and Family Services and the Ohio Rehabilitation Services Commission to release medical, psychological, psychiatric, pharmaceutical, vocational and social information. I

understand this may include personally identifying information that is casually or historically related to my physical or mental injuries relevant to issues necessary for the administration of my claim to BWC, the

Industrial Commission of Ohio, the employer in this claim, the employer’s managed care organization and any authorized representatives. My previous or future BWC claims may affect decisions made in this claim.

Proper administration of the present claim may require BWC to share claims information with the employers of record (or their authorized representatives) and/or my authorized representative for any and all such

previous or future claims. The released claims information may include any record maintained in my claim ﬁles.

Injured worker signature

Date

E-mail address

Telephone number

Work number

( )

1 Home address: Enter the home address where the

9 Date last worked: Enter the last day worked as a result

injured worker lives. Include the apartment number,

of this injury, occupational disease or death.

if applicable.

• If the post ofice does not deliver mail to the

Date returned to work: Enter the date the injured

home address, list the mailing address instead

worker returned to work after the injury or

of the home address.

occupational disease.

info.

Department name: Enter the injured worker's

11 State where hired: Enter the state where the injured

department or area name where he/she normally

worker was hired by the employer listed on this

reports for work.

application.

injury/disease/death

3 Wage rate: Enter the injured worker's rate of pay, and

12 Date employer notiied: Enter the date the employer

then select how often it is received. (If the pay rate

wasnotiiedoftheinjury,occupationaldiseaseordeath.

being reported is not hourly, report the gross amount.)

• If eight or more days of work will be missed, BWC

13 State where supervised: Enter the state where the

needs wage information for the 52 weeks prior to

injuredworkerwassupervisedbytheemployerlisted

the date of injury. Submit wage information using

on this application.

employer payroll reports, wage statement (BWC

form C-94-A), W-2s, etc.

14 Description of accident: Describe in detail the events

4 What days of the week do you usually work? What

that caused the injury, occupational disease or death.

are your regular work hours: Enter the days and

Attach additional sheets, if necessary.

and

hours the injured worker normally works.

• If the days worked vary from week to week, list the

Type of injury/disease and part of body affected:

worker

number of hours worked in an average week.

Describethenatureoftheinjury,occupationaldisease

Wages:Ifyoureceivedwagesduringdisability,please

or death.

Indicate the part(s) of body injured, affected or that

explain.

caused the death.

Injured

6 Occupationorjobtitle:Entertheinjuredworker'stype

Examples:

• Laceration of irst toe, left foot;

of occupation or actual job title at the time of injury,

• Sprain of lower right back; etc.

occupational disease or death.

16 Injured worker signature (injured workers only):

Employer name: Enter the name of the injured

Please

read

the

Benefit application/medical

worker's

employer at the time of

the

injury,

release information before signing and dating

occupational disease or death.

this form.

8 Date of injury/disease: Enter the date injured worker

was injured. OR

If the injured worker contracted an occupational

Instructions

disease, determine which of the following happened

continued

most recently:

on last page

• The occupational disease was diagnosed by a medical provider;

[

• The irst medical treatment;

• The injured worker irst quit work, due to the occupational disease.

Enter this as the date of occupational disease.

First Report of an Injury,

Occupational Disease or Death

WARNING:

By signing this form, I:

• Elect to only receive compensation and/or beneits that are provided for in this claim under Ohio workers' compensation laws;

Any person who obtains compensation from

• Waive and release my right to receive compensation and beneits under the workers' compensation laws of another state for

BWC or self-insuring employers by knowingly

the injury or occupational disease, or death resulting from an injury or occupational disease, for which I am iling this claim;

misrepresenting or concealing facts, making false

• Agree that I have not and will not ile a claim in another state for the injury or occupational disease or death resulting from an

statementsoracceptingcompensationtowhichhe

injury or occupational disease for which I am iling this claim;

or she is not entitled, is subject to felony criminal

• Conirm that I have not received compensation and/or beneits under the workers’ compensation laws of another state for this claim,

prosecution for fraud.

and that I will notify BWC immediately upon receiving any compensation or beneits from any source for this claim.

(R.C. 2913.48)

Last name, ﬁrst name, middle initial

Social Security number

Marital status

Date of birth

Single

Home mailing address

Sex

Married

Number of dependents

Male

Female

Divorced

Separated

City

State

9-digit ZIP code

Country if different from USA

Department name

Widowed

Wage rate

Hour

Month

Week

What days of the week do you usually work?

Regular work hours

Per:

Year

Other

Sun

Mon

Tues

Wed

Thur

Fri

Sat

From

info.

Have you been offered or do you expect to receive payment or wages for this claim from anyone other than the Ohio Bureau

Occupation or job title

of Workers' Compensation?

Yes

If yes, please explain.

Employer name

injury/disease/death

Mailing address (number and street, city or town, state, ZIP code and county)

Location, if different from mailing address

Was the place of accident or exposure on employer's premises?

Yes

(If no, give accident location, street address, city, state and ZIP code)

Date of injury/disease

Time of injury

If fatal, give date of death

Time employee

Date last worked

Date returned to work

a.m.

p.m.

began work

a.m.

p.m.

and

Date hired

State where hired

Date employer notiﬁed

State where supervised

Injured worker

Description of accident (Describe the sequence of events that directly

Type of injury/disease and part(s) of body affected

injured the employee, or caused the disease or death.)

(For example: sprain of lower left back)

Beneﬁt application release of information – I am applying for a claim under the Ohio Bureau of Workers’ Compensation Act for work-related injuries that I did not inﬂict. I afﬁrm that I elect to receive compensation and beneﬁts under Ohio's workers’ compensation laws for my claim, and I waive and release my right to ﬁle for and receive compensation and beneﬁts under the laws of any other state for this claim. I request payment for compensation and/ or medical beneﬁts as allowable, and authorize direct payment to my medical providers. I permit and authorize any provider who attends, treats or examines me, the Ohio State Board of Pharmacy, the Ohio Department of Job and Family Services and the Ohio Rehabilitation Services Commission to release medical, psychological, psychiatric, pharmaceutical, vocational and social information. I understand this may include personally identifying information that is casually or historically related to my physical or mental injuries relevant to issues necessary for the administration of my claim to BWC, the Industrial Commission of Ohio, the employer in this claim, the employer’s managed care organization and any authorized representatives. My previous or future BWC claims may affect decisions made in this claim. Proper administration of the present claim may require BWC to share claims information with the employers of record (or their authorized representatives) and/or my authorized representative for any and all such previous or future claims. The released claims information may include any record maintained in my claim ﬁles.

Injured worker signature	Date	E-mail address	Telephone number	Work number
				(	)

Treatment info.

Health-care provider name	Telephone number		Fax number			Initial treatment date
	(	)	(	)
Street address	City				State	9-digit ZIP code

Diagnosis(es): Include ICD code(s)

Will the incident cause the injured worker to
miss eight or more days of work?	Yes	No	Is the injury causally related to the industrial incident?			Yes	No

E code				11-digit BWC provider number	Date

Health-care provider signature

Employer policy number

Check

Employer is self-insuring

Injured worker is owner/partner/member of ﬁrm

Telephone number

Fax number

E-mail address

Federal ID number

Manual number

(

)

(

)

info.

Was employee treated in an emergency room?

Yes No

Was employee hospitalized overnight as an inpatient?

Yes No

Employer

If treatment was given away from work site, provide the facility name, street address, city, state and ZIP code

Certiﬁcation - The employer

Rejection - The employer

For self-insuring employers only

Clariﬁcation - The employer clariﬁes

certiﬁes that the facts in this

rejects the validity of this claim for

application are correct and valid.

the reason(s) listed below:

and allows the claim for the condition(s) below:

Medical only

Lost time

Employer signature and title

Date

OSHA case number

BWC-1101 (Rev. 6/12/2014)

This form meets OSHA 301 requirements

FROI-1 (Combines C-1, C-2, C-3, C-6, C-50, OD-1, OD-1-22)

Completion instructions

(continued)

Treatment info.

Health-care provider name

Telephone number

Fax number

Initial treatment date

(

)

(

)

info.

Street address

City

State

9-digit ZIP code

Diagnosis(es): Include ICD code(s)

Treatment

SAMPLE

E code 3

11-digit BWC provider number

Date

Will the incident cause the injured worker to miss eight or more

days of work?

Yes

Is the injury causally related to the industrial incident?

Yes

Health-care provider signature

1Indicate the diagnosis and ICD codes for conditions being treated as a result of the injury.

2Indicate the treating provider's medical opinion that the injury sustained is causally related to the industrial incident, that the injury could result from the method (manner) of the accident, as described by the injured worker. It must be clear that the diagnosis in all probability occurred as a result of the injury.

3Providing a valid E code will enable us to determine the claim more quickly and eficiently.

4Enter the physician's or health-care provider's 11-digit BWC-assigned provider number.

5Signature of the health-care provider completing this form.

1 Employer policy number

Check

Employer is self-insuring

Injured worker is owner/partner/member of ﬁrm

info.

Telephone number

Fax number

E-mail address

Federal ID number

Manual number

(

)

( )

Was employee treated in an emergency room?

Yes

Was employee hospitalized as an inpatient?

Yes

If treatment was given away from work site, provide the facility name, street address, city, state and ZIP code

Certiﬁcation - The employer

Rejection - The employer

For self-insuring employers only

Employer

certiies that the facts in this

SAMPLE

Clariﬁcation - The employer clariies

rejects the validity of this claim for

application are correct and valid.

the reason(s) listed below:

5 and allows the claim for the condition(s) below:

Employer: signature and title

Date

OSHA case number 6

Employer info.

1Enter the employer's BWC-assigned policy number, which is located on the BWC certiicate of coverage.

2Enter the four-digit code that indicates the injured worker's job classiication, located on the semiannual payroll report.

•If you do not know the injured worker's manual number, call 1-800-644-6292 and follow the prompts.

3If certiication is selected and the claim is allowed, it will promptly be paid. Employers certifying a claim waive both the notice of receipt and notice of irst order of compensation.

4If rejection is selected, use the space provided to list the reasons for rejection. Attach additional sheets, if necessary.

5Self-insuring employers that choose to clarify certiication may use the space provided. Attach additional sheet, if necessary.

6If this is an OSHA-reportable injury, include the case number assigned by the employer.This form meets OSHA 301 requirements and may be used in lieu of the OSHA 301 when reporting recordable injuries and illnesses to the federal government.

Note:

If your employee misses eight or more days of work, BWC will need wage information for the 52 weeks prior to the date of injury. Submit wage information using employer payroll reports, wage statement (BWC form C-94-A), W-2s, etc.

⇩ PDF

Document Specifications

Fact Name	Details
Purpose	The DRsxxx form, known as the First Report of an Injury, Occupational Disease, or Death, is used to report workplace incidents to the Ohio Bureau of Workers' Compensation (BWC).
Submission Method	This form can be completed and submitted online at www.bwc.ohio.gov. Alternatively, it can be mailed or faxed to the employer or their managed care organization (MCO).
Injured Worker Actions	The injured worker should fill out as much of the form as possible before submitting it. If completed at a medical provider's visit, the provider can assist with filling out treatment information.
MCO Information	If the injured worker does not know their employer's MCO, they can contact BWC at 1-800-644-6292 or check the BWC website for assistance.
Self-Insuring Employers	Injured workers employed by self-insuring employers must submit this form directly to their employer. There may be processing delays if the information is filed with BWC.
Legal Authority	The form is governed by Ohio's Workers' Compensation Act (R.C. 4123), which outlines the laws and guidelines for reporting workplace injuries and processing claims.

Steps to Filling Out Drsxxx

It is essential to fill out the Drsxxx form carefully and accurately to ensure your claim is processed without unnecessary delays. This form must be submitted to your employer or their managed care organization (MCO) after completion. Follow these steps to fill out the form correctly:

Provide Personal Information: Fill in your last name, first name, middle initial, and Social Security number. Select your marital status, date of birth, home mailing address, sex, and number of dependents.
Input Employment Details: Enter the department name, your occupation or job title, and the name of your employer.
Wages and Work Schedule: Specify your wage rate and how often you receive it (hourly, monthly, etc.). Indicate your usual workdays and your regular work hours.
Injury Information: Note the date of the injury, time of injury, and if applicable, the date of death. Provide a description of the accident and the type of injury or disease.
Employer Notification: Record the date you notified your employer and the state where you were hired. Include the location of the accident.
Medical Provider Details: Fill out the section regarding treatment, including the healthcare provider’s name, initial treatment date, diagnosis, and whether the incident will cause you to miss work.
Signature: Sign and date the form, then provide your email address and contact numbers.

After completing the form, please ensure to submit it through the appropriate channels. Remember to contact BWC if you encounter any uncertainties regarding the process or your employer's MCO.

More About Drsxxx

What is the purpose of the Drsxxx form?

The Drsxxx form, also known as the First Report of an Injury, Occupational Disease or Death, is used to report work-related injuries, occupational diseases, or fatalities to the Ohio Bureau of Workers' Compensation (BWC). This form initiates the claims process and captures essential information about the incident and the injured worker.

How do I submit the Drsxxx form?

You can complete and submit the Drsxxx form online at the BWC's website, www.bwc.ohio.gov. If you prefer, you may also deliver, mail, or fax a completed form to your employer or their managed care organization (MCO). Be sure to include all relevant details in every section to help speed up the claim process.

What information is required in the Drsxxx form?

The form requires several details, including the injured worker's personal information, details about the incident, and the type of injury or disease. You’ll need to provide your name, Social Security number, employer information, the date and time of the incident, and a description of the injury or illness. Complete as much of the form as possible to minimize delays.

What if my employer is self-insuring?

If you are employed by a self-insuring employer, the process is slightly different. You must still complete the form but provide it directly to your employer. Self-insured employers manage their own worker compensation claims, which may cause processing delays as they evaluate the claims.

What if I don’t know my employer’s MCO?

If you are unaware of your employer's managed care organization, you can obtain this information by contacting the BWC at 1-800-644-6292. Alternatively, you can look for your employer's MCO on the BWC’s website. If all else fails, you can submit the form directly to your local BWC customer service office.

Can I fill out this form at my medical provider’s office?

Yes, if you complete the Drsxxx form at your first medical provider's visit, you can give the form to the provider. They will fill out the treatment information section and subsequently submit the completed form to your MCO or the BWC, as appropriate.

What if I have missed work due to my injury?

If your injury or illness leads you to miss eight or more days of work, detailed wage information will be required for the year preceding the incident. This information should be submitted using employer payroll reports, wage statements, or tax documents such as W-2s.

Is there a deadline for submitting the Drsxxx form?

What happens after I submit the Drsxxx form?

Common mistakes

Filling out the Drsxxx form can be a nuanced process, and many individuals unknowingly make mistakes that can delay their claim or lead to complications. Here is an expanded list of common errors made:

Incomplete Information:
Many people fail to complete all sections of the form. Providing partial information can prolong the claims process.
Incorrect Social Security Number:
Entering the wrong Social Security number can lead to mismatches in the system, causing delays in processing.
Improper Wage Reporting:
Sometimes, individuals report their wage rate incorrectly. It's crucial to select the right time frame (hourly, monthly, weekly) to avoid confusion.
Missing Employer Information:
Failure to provide complete employer details, such as name and address, can hinder communication and necessary follow-ups.
Neglecting to Specify Injury Details:
Individuals often omit specific details about the injury. A detailed description aids in the accurate assessment of the claim.
Failing to Sign the Form:
It’s imperative that the injured worker signs the form. Without a signature, the application cannot be processed.
Skipping the Treatment Section:
Not providing information about medical treatment received can limit the ability to process the claim, especially when medical benefits are involved.
Not Acknowledging Paid Time Off:
Failing to disclose whether payment or wages are expected from any source other than the Bureau of Workers' Compensation can complicate claims.
Lack of Clarity in Description of Events:
Many forms lack clear descriptions of the sequence of events leading to the injury. Clarity helps assess the cause effectively.
Failure to Submit on Time:
Finally, submitting the form late can impede the claims process. It is essential to be mindful of deadlines associated with the form submission.

Correcting these common mistakes can significantly improve the likelihood of a smooth and timely claims process for work-related injuries or illnesses.

Documents used along the form

When managing a claim for a work-related injury or occupational disease, several additional documents are often utilized alongside the Drsxxx form. These documents facilitate a smoother claims process and help ensure all necessary information is submitted. Below is a list of commonly used forms, each with a brief description.

C-1 Form: This is typically the first report form that employers must file with the Bureau of Workers’ Compensation (BWC). It details the injury or incident from the employer’s perspective.
C-2 Form: Used to provide a detailed description of the work-related injury from the employee’s viewpoint, the C-2 form complements the C-1 by adding the injured worker’s narrative.
C-3 Form: This form is vital for initiating a lost-time claim. It documents the injured worker's absence from work due to the injury and requests benefits for lost wages.
C-6 Form: The medical authorization form allows health care providers to release the injured employee's medical records to the BWC, facilitating the evaluation of the claim.
C-94-A Form: This wage information form must be completed if the injured worker misses more than eight days of work. It provides the BWC with the necessary wage data for compensation calculations.
E-1 Form: In cases where the worker is self-insured, the E-1 keeps the employer informed and helps them verify details related to the claim.
FROI-1 Form: This comprehensive form combines multiple earlier forms and is used to streamline initial claims by collecting essential details from both the employer and employee.
ICD Codes: Healthcare providers must include International Classification of Diseases (ICD) codes, which categorize injuries and diseases related to the claim, making it easier to determine eligibility for benefits.
OSHA 301 Form: If the incident resulted in a serious injury, the OSHA 301 form is used to document the specifics of the incident for workplace safety requirements in addition to the workers’ compensation claim.

These documents play crucial roles in ensuring all aspects of a workers' compensation claim are thoroughly addressed. Properly completing and submitting these forms can greatly impact the expeditious processing of claims and the injured worker's ability to receive necessary benefits. Taking time to understand each form and its purpose helps to alleviate potential confusion during this often stressful period.

Similar forms

The Drsxxx form, serving as the First Report of an Injury, Occupational Disease, or Death, has similarities with several other crucial documents used in workers’ compensation claims. One such document is the Employee’s Claim for Compensation, often referred to as the C-3 form. This form is essential for employees to formally initiate a claim for benefits after sustaining an injury or illness at work. Similar to the Drsxxx form, the C-3 requires detailed information about the employee’s injury, including the nature of the injury and circumstances surrounding it. Both forms facilitate the processing of claims, ensuring that injured workers can access necessary benefits without undue delay. Completing either document accurately helps the Bureau of Workers' Compensation (BWC) expedite decision-making regarding claims.

Another document closely related to the Drsxxx form is the Employer’s Report of Injury, commonly known as the C-1 form. This report is filed by employers following an employee's injury and serves to provide the BWC with critical facts about the incident. Like the Drsxxx form, the C-1 includes details such as the time and location of the injury and a description of the circumstances. These documents work in tandem to create a comprehensive account of the incident, supporting the injured worker's claim while ensuring that employers fulfill their reporting obligations. Each form plays a vital role in the overall claims process and protects the rights of both employees and employers.

The Incident Report is yet another document similar to the Drsxxx form. Often completed by supervisors or managers, an Incident Report provides a factual narrative of the event that led to the injury. While the Drsxxx form focuses on the affected worker's details and claim for compensation, the Incident Report addresses the broader context of the accident. Both require precise information and can be critical in establishing liability and verifying the circumstances of the incident. Enhancing the accuracy of the claims process, these forms collectively contribute to a thorough understanding of workplace safety and injury prevention.

The Treatment Authorization form serves as another important document in tandem with the Drsxxx form. This form is utilized by healthcare providers to obtain approval for specific treatments related to workplace injuries. Like the Drsxxx form, it requires information about the injured worker and the medical treatment proposed. Both documents are essential in ensuring that appropriate medical care is covered under workers’ compensation and affirm the necessity of treatment for the injured worker's recovery. These supporting documents help safeguard access to medical benefits and ensure that injured employees receive the care they need promptly.

Lastly, the Vocational Rehabilitation Plan is comparable to the Drsxxx form in its purpose of assisting injured workers in returning to the workforce. While the Drsxxx form initiates the claims process following an injury, the Vocational Rehabilitation Plan outlines the steps necessary for rehabilitation and re-employment of the injured worker. Both documents share the goal of promoting recovery and ensuring workers are supported through their journey back to their jobs. They are integral to creating a comprehensive support system that addresses the multifaceted needs of injured employees, maintaining their dignity and work-related entitlement.

Dos and Don'ts

Do complete all sections of the Drsxxx form thoroughly.
Do provide accurate information regarding your injury, including dates and descriptions.
Do submit the form to your employer or their managed care organization immediately.
Do contact the BWC if you are unsure of your employer's managed care organization.
Don't leave any sections blank; incomplete forms can delay processing.
Don't provide information that is not true or accurate; this could lead to legal issues.
Don't wait too long to file, as there may be deadlines associated with your claim.

Misconceptions

Understanding the Drsxxx form, officially known as the First Report of an Injury, Occupational Disease, or Death, is essential for injured workers and employers alike. However, several misconceptions can lead to confusion and missteps in the claims process. Below is a list of five common myths accompanied by explanations to clarify the facts.

Misconception 1: The form can only be submitted by the employer.

In reality, the injured worker can complete and submit the form as well. If the worker fills it out during their first medical visit, they can have the medical provider complete the necessary sections before submission.

Misconception 2: You cannot file a claim if you miss less than eight days of work.

This is not true. Even if a worker anticipates returning to work shortly, they should still report the injury. Filing the form helps ensure that the claim is on record in case complications arise later on.

Misconception 3: The Drsxxx form must be filed immediately after an injury occurs.

While it is best to file the form as soon as possible, it is not mandatory to do so immediately. Prompt reporting helps in the smooth processing of claims, but a reasonable delay does not invalidate the claim.

Misconception 4: The employer will automatically know if an employee has been injured on the job.

Employers are not always aware of on-the-job injuries unless the employee communicates them. It is the injured worker's responsibility to ensure that their employer is informed about the injury, along with submitting the required form.

Misconception 5: Self-insured employers have a different filing process that takes longer.

While the process for self-insured employers may differ slightly, it does not inherently cause delays. Injured workers must still complete the form accurately and submit it just like any other claim. The key is ensuring clear communication with the self-insuring employer about their policies and procedures.

Key takeaways

When filling out and using the Drsxxx form, it's important to follow certain guidelines to ensure your claim is processed smoothly. Here are some key takeaways:

Complete all sections of the form to help speed up your claim processing. It is best if the injured worker fills it out during their first visit to a medical provider.
After filling out the form, you can deliver it to your employer or send it using mail or fax. Make sure to double-check that you've sent it to the right place.
If uncertain about your employer's managed care organization (MCO), you can call BWC at 1-800-644-6292 or visit their website for assistance.
For those working with self-insuring employers, make sure you inform your employer about the injury and submit the form to them directly.
If you need help while completing the form, don't hesitate to call your local BWC customer service office. They are available to assist you during business hours.