Nothing Special   »   [go: up one dir, main page]
Scribd Logo
Upload

Welcome to Scribd!

  • 30 views

    Missouri Report Your Workplace Injury or Occupational Disease or Repetitive Trauma Injury

    Uploaded by

    itargeting
    The document provides instructions for employees in Missouri to report a workplace injury or occupational disease to their employer. It outlines that employees must provide written notice to their employer within 30 days of an injury or diagnosis to protect their ability to receive workers' compensation benefits. The notice should include the date, time, location and description of the injury. It advises keeping a copy of the notice submitted. Employees can call a toll-free number if they require assistance in obtaining medical treatment or benefits.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Missouri Report Your Workplace Injury or Occupational Disease or Repetitive Trauma Injury

    Uploaded by

    itargeting
    30 views1 page
    The document provides instructions for employees in Missouri to report a workplace injury or occupational disease to their employer. It outlines that employees must provide written notice to their employer within 30 days of an injury or diagnosis to protect their ability to receive workers' compensation benefits. The notice should include the date, time, location and description of the injury. It advises keeping a copy of the notice submitted. Employees can call a toll-free number if they require assistance in obtaining medical treatment or benefits.

    Original Description:

    Missouri Report Your Workplace Injury or Occupational Disease or Repetitive Trauma Injury

    Copyright

    © © All Rights Reserved

    Available Formats

    PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    The document provides instructions for employees in Missouri to report a workplace injury or occupational disease to their employer. It outlines that employees must provide written notice to their employer within 30 days of an injury or diagnosis to protect their ability to receive workers' compensation benefits. The notice should include the date, time, location and description of the injury. It advises keeping a copy of the notice submitted. Employees can call a toll-free number if they require assistance in obtaining medical treatment or benefits.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    30 views1 page

    Missouri Report Your Workplace Injury or Occupational Disease or Repetitive Trauma Injury

    Uploaded by

    itargeting
    The document provides instructions for employees in Missouri to report a workplace injury or occupational disease to their employer. It outlines that employees must provide written notice to their employer within 30 days of an injury or diagnosis to protect their ability to receive workers' compensation benefits. The notice should include the date, time, location and description of the injury. It advises keeping a copy of the notice submitted. Employees can call a toll-free number if they require assistance in obtaining medical treatment or benefits.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 1

    MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS

    REPORT YOUR WORKPLACE INJURY/OCCUPATIONAL


    DISEASE OR REPETITIVE TRAUMA INJURY

    800-775-2667
    www.labor.mo.gov/DWC

    If your employer does not provide you with a form to complete to report your injury, you may use this form to
    provide the employer with written notice of your accident or injury;
    If you choose to use this form it does not replace the incident or accident form that your employer may require you to
    complete;
    If you choose to use this form, PLEASE DO NOT send it to the state or to the Missouri Division of Workers
    Compensation (Division);
    This is not a Claim for Compensation form;
    Under Missouri law you are required to report your injury to your employer in writing within 30 days of the injury.
    Failure to report your injury to your employer within 30 days may jeopardize your ability to receive workers
    compensation benefits UNLESS the Division or Commission finds that the employer is not prejudiced by failure to
    receive the notice;
    Under Missouri law, your employer or its workers compensation insurance company or third-party administrator
    should arrange for you to receive the medical treatment as may be reasonably required to cure and relieve you from
    the effects of the injury.
    Under Missouri law, the employer files a separate First Report of Injury with the Division pursuant to
    287.380, RSMo.
    Your written notification to the employer should include the following information:
    Date Written Notice Given: __________________________________________________________________________
    Name of Person Injured: _____________________________________________________________________________
    Address of Person Injured: ___________________________________________________________________________
    Date of Injury: ____/____/________
    Time of Injury: _____:_____

    a.m. /

    p.m.

    Place of Injury: ____________________________________________________________________________________


    Nature of the Injury: ________________________________________________________________________________
    NOTE:
    Failure to provide written notice of your occupational disease or repetitive trauma injury to your employer within
    30 days of the diagnosis of your condition may jeopardize your ability to receive workers compensation benefits
    UNLESS the Division or Commission finds that the employer is not prejudiced by failure to receive the notice.
    Make a copy of this written notice or the written notice your employer gives you to complete and keep a record of the date
    you provided your notice. If you hand-deliver your notice, keep a record of the date and time of the delivery along with
    the full name and title of the person you delivered it to.
    To verify that your injury has been reported or to speak to an Information Specialist, please call the Divisions toll free
    number 800-775-2667. If you experience difficulty in obtaining medical treatment or other benefits, call the number
    above and request Dispute Management Assistance.
    WC-280 (03-12) AI

    You might also like