Form ADM4303 "Injury/Illness Report" - Ohio

What Is Form ADM4303?

This is a legal form that was released by the Ohio Department of Administrative Services - a government authority operating within Ohio. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on December 1, 2018;
  • The latest edition provided by the Ohio Department of Administrative Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form ADM4303 by clicking the link below or browse more documents and templates provided by the Ohio Department of Administrative Services.

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Download Form ADM4303 "Injury/Illness Report" - Ohio

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Employee Instructions for completing the ADM 4303 Injury / Illness Report
This form must be completed as part of the workers’ compensation application process. Failure to fully complete this report may
result in the denial or delay of benefits. Write legibly with a black or blue ink pen (do not use pencil) or file electronically.
Employee Statement
The injured employee is responsible for completing the following sections:
Personal Information- Please fully complete all requested information.
Incident report Information
You must notify your supervisor immediately (within 24 hours) after any accident or onset of illness.
Follow your specific agency’s accident procedures
Provide the exact date and time the accident occurred
Provide the exact date and time the incident was reported
List to whom (name, title and phone #) you reported the incident
Off Work Benefits – you must make a selection, refer to your specific bargaining unit contract for details. You cannot collect
temporary total compensation, salary continuation or OIL benefits during the same period of time.
Temporary Total Compensation (TT) – TT benefits are paid by the Bureau of Workers’ Compensation (BWC). Your
injury must result in eight (8) or more calendar days of lost time from work before TT is considered. Please refer to
www.ohiobwc.com for specific details
Salary Continuation (SC) – SC is equal to the employee’s total rate of pay not to exceed 480 hours per workers’
***
compensation claim and paid by the employer.
Occupational Injury Leave (OIL) – An employee who incurs a work-related injury or illness inflicted by a ward of the
***
State may be entitled to OIL. OIL is equal to the employee’s total rate of pay not to exceed 960 hours per workers’
compensation claim and paid by the employer. Refer to your specific bargaining unit contract for details, as OIL applies to
certain agencies.
WILMAPC PROVIDER
***
IN ORDER TO QUALIFY FOR SALARY CONTINUATION OR OCCUPATIONAL INJURY LEAVE, YOU MUST SEEK
MEDICAL TREATMENT WITHIN 7 DAYS OF THE DATE OF INJURY FROM A PHYSICIAN ON THE WILMAPC
APPROVED PHYSICIAN LIST.
YOU MAY ACCESS THE WILMAPC PROVIDER LIST OR CONTACT YOUR MCO REPRESENTATIVE
http://www.das.ohio.gov/wilmapc
Employee Accident Description
You must explain in DETAIL how you were injured, including
What caused the injury/illness, where the accident occurred, how the accident occurred, explain what you were doing at
the time of the accident, include the ACTUAL SPECIFIC location where the incident occurred and list any witnesses to the
incident
Nature of Injury/Illness
Indicate the body part affected and the illness or injury that resulted from the incident. Include details of any medical attention sought
or plan to seek.
Did you seek on-site medical treatment? Check yes or no. If yes, provide details of treatment rendered in “nature of
Injury/Illness” section.
Be sure to indicate name medical provider
Injured Worker Signature/Date
Please read and complete this form in its entirety. Be sure to date and sign it before returning it to your employing agency
designee/personnel officer.
NOTICE: “The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA
Title II from requesting or requiring genetic information of an individual or family member of the individual, except as
specifically allowed by this law. To comply with this law, we are asking that you not provide any genetic information when
responding to this request for medical information. “Genetic information”, as defined by GINA, includes an individual’s
family medical history, the results of an individual’s or family member’s genetic tests, the fact that an individual or an
individual’s family member sought or received genetic services, and genetic information of a fetus carried by an individual
or an individual’s family member or an embryo lawfully held by an individual or family member receiving assistive
reproductive services.”
ADM 4303 (Rev. 12/2018)
Employee Instructions for completing the ADM 4303 Injury / Illness Report
This form must be completed as part of the workers’ compensation application process. Failure to fully complete this report may
result in the denial or delay of benefits. Write legibly with a black or blue ink pen (do not use pencil) or file electronically.
Employee Statement
The injured employee is responsible for completing the following sections:
Personal Information- Please fully complete all requested information.
Incident report Information
You must notify your supervisor immediately (within 24 hours) after any accident or onset of illness.
Follow your specific agency’s accident procedures
Provide the exact date and time the accident occurred
Provide the exact date and time the incident was reported
List to whom (name, title and phone #) you reported the incident
Off Work Benefits – you must make a selection, refer to your specific bargaining unit contract for details. You cannot collect
temporary total compensation, salary continuation or OIL benefits during the same period of time.
Temporary Total Compensation (TT) – TT benefits are paid by the Bureau of Workers’ Compensation (BWC). Your
injury must result in eight (8) or more calendar days of lost time from work before TT is considered. Please refer to
www.ohiobwc.com for specific details
Salary Continuation (SC) – SC is equal to the employee’s total rate of pay not to exceed 480 hours per workers’
***
compensation claim and paid by the employer.
Occupational Injury Leave (OIL) – An employee who incurs a work-related injury or illness inflicted by a ward of the
***
State may be entitled to OIL. OIL is equal to the employee’s total rate of pay not to exceed 960 hours per workers’
compensation claim and paid by the employer. Refer to your specific bargaining unit contract for details, as OIL applies to
certain agencies.
WILMAPC PROVIDER
***
IN ORDER TO QUALIFY FOR SALARY CONTINUATION OR OCCUPATIONAL INJURY LEAVE, YOU MUST SEEK
MEDICAL TREATMENT WITHIN 7 DAYS OF THE DATE OF INJURY FROM A PHYSICIAN ON THE WILMAPC
APPROVED PHYSICIAN LIST.
YOU MAY ACCESS THE WILMAPC PROVIDER LIST OR CONTACT YOUR MCO REPRESENTATIVE
http://www.das.ohio.gov/wilmapc
Employee Accident Description
You must explain in DETAIL how you were injured, including
What caused the injury/illness, where the accident occurred, how the accident occurred, explain what you were doing at
the time of the accident, include the ACTUAL SPECIFIC location where the incident occurred and list any witnesses to the
incident
Nature of Injury/Illness
Indicate the body part affected and the illness or injury that resulted from the incident. Include details of any medical attention sought
or plan to seek.
Did you seek on-site medical treatment? Check yes or no. If yes, provide details of treatment rendered in “nature of
Injury/Illness” section.
Be sure to indicate name medical provider
Injured Worker Signature/Date
Please read and complete this form in its entirety. Be sure to date and sign it before returning it to your employing agency
designee/personnel officer.
NOTICE: “The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA
Title II from requesting or requiring genetic information of an individual or family member of the individual, except as
specifically allowed by this law. To comply with this law, we are asking that you not provide any genetic information when
responding to this request for medical information. “Genetic information”, as defined by GINA, includes an individual’s
family medical history, the results of an individual’s or family member’s genetic tests, the fact that an individual or an
individual’s family member sought or received genetic services, and genetic information of a fetus carried by an individual
or an individual’s family member or an embryo lawfully held by an individual or family member receiving assistive
reproductive services.”
ADM 4303 (Rev. 12/2018)
Injury / Illness Report
Check all that apply:
____ OCSEA
Unit _______
FOR OFFICE USE ONLY
____ Full time Employee
____ FOP Unit 2
Employee Statement
(completed by employee)
____ Part-time Employee
____ 1199
____ Interim Employee
____ ORC 124.381
PERSONAL INFORMATION
____ Exempt
____ ORC 124.15
____ Seasonal / temp
____ OSTA
Employee’s name:
____ Other: __________
____ Other: _____
Address
Social Security #:
(Street / City / State / Zip):
Phone #
Date of Birth:
Age:
Sex:
(Home / Work):
Your employer’s name:
Employer’s BWC Policy #:
Job Title:
Regular work hours: From ______ am/pm To ______ am/pm
Work Days: ___Sun ___Mon ___Tues ___Weds ___Thurs ___Fri ___Sat
INCIDENT REPORT INFORMATION
OFF WORK BENEFITS:
Check one benefit type:
Date/Time of Injury:
____ Temporary Total Compensation
Were you working overtime when this injury occurred? ____ Yes ____ No
____ Salary Continuation*
____ Occupational Injury Leave*;
inflicted by a ward of the
Reported to
Date/Time Reported:
(Name/Title):
State (inmate, patient, resident, client, youth or student)
*Must seek medical treatment from WILMAPC
approved provider
Exact location of incident (Include name of building/area and location within building/area or town, county, State Route or mile marker):
Were there any witnesses? Please list names:
Are you working, in any capacity, for another employer: ____Yes ____ No
If yes, employer name:
EMPLOYEE ACCIDENT DESCRIPTION
(Please DESCRIBE how the injury happened in DETAIL)
What duties were you performing?
What caused the injury? (e.g. I slipped on the ice.)
NATURE OF ILLNESS/INJURY
(PLEASE BE VERY SPECIFIC)
Indicate body part(s) affected:
Describe the illness or injury resulting from the incident:
On-site medical treatment sought/rendered? ____Yes
____ No
If yes, from?
Clinician observation / assessment:
Clinician initials: ____________
Outside medical treatment sought/rendered? ____Yes
____No
(If yes, provide the name and phone number of medical provider below)
Physician’s name & phone #:
Benefit application/medical release – I am applying for a claim under the Ohio Workers’ Compensation Act for work-related injuries that I did not purposely inflict. I affirm that I elect to
receive benefits under the Ohio 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, and the Ohio Rehabilitation Services Commission (where relevant) to release medical, psychological, psychiatric, vocational or social information that
is causally 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, DAS,
employing agency, the employer’s BWC MCO and their authorized representatives. I understand that social security numbers are used to match individuals with other employment records
that may be required in the processing of this claim and are used for informational purposes only. A photocopy of this authorization shall be as valid as the original.
Employee Signature
Date
ADM 4303 (Rev. 12/2018)
DISTRIBUTION: File / MCO / BWC /TPA / Employee
Page 1 of 2
Injury / Illness Report
Date received by personnel:
Employer Statement
(completed by WC designee)
EMPLOYER INFORMATION
BWC Claim #
and/or injury date:
Employee’s Name:
Agency
(Specify operating location
BWC Policy #:
or Central Office):
Address
Work County:
(Street / City / State / Zip):
Hire date:
Employment type:
_____PT
_____FT
_____Interim
_____Temp
Bargaining Unit Status:
OCSEA Unit __________________
FOP_____
1199_____
Exempt_____
Other: ____________
Did employee seek nursing/first aid care? _____Yes
_____No
If yes, from?
Was employee hospitalized overnight as in-patient? _____Yes
_____ No Or treated in the Emergency Room? _____Yes _____No
Was employee off work seven (7) consecutive days? _____Yes
______No
Did employee use sick leave, vacation leave, personal leave, or any other leave with pay for any of the lost work days? _____Yes
_____No
If yes, have you attached a calendar of wages showing leave usage? _____Yes
______No
Has the employee returned to work? _____Yes
_____No
What was the last date the employee worked?
If YES, give ACTUAL date:
If NO, give estimated RTW date:
DATE _____________________________
Was a Transitional Work Assignment offered to this employee? ______Yes
_____No
Is a Position Description and / or Job Analysis attached?
______Yes
_____No
Did this injury result in a fatality? _____Yes
_____No
If yes, give date of death:
Date faxed/called in to MCO:
By whom:
Employee has applied for payment under: _____Salary Continuation _____OIL _____BWC-TT _____Disability
Other: _______________
SC or OIL BENEFITS:
(Check if applicable) A completed calendar of wages must be submitted if SC or OIL is requested
_____ SALARY CONTINUATION
OIL - Do you believe this is a legitimate OIL injury? ___ Yes ___ No
Appointing Authority Signature: __________________________________
_____ OCCUPATIONAL INJURY LEAVE
Date:
Coordinator’s initials:
Date employee became disabled:
Comments:
Total hours being requested:
Treating with an approved WILMAPC physician?___Yes ___No
EMPLOYER CLAIM CONTACT
(please print clearly)
Name
Title
Phone #
EMPLOYER CLAIM POSITION
(check applicable section)
_____ CERTIFICATION
_____ UNKNOWN
_____ REJECTION
Based on the information known at this time the
This claim is still in process and
The employer rejects the claim for the
employer CERTIFIES that the facts in this
pending further investigation and claim
following reason(s):
application are correct and valid. This certification
research.
does not waive any appeal rights that may exist if
the employer so chooses to exercise those rights.
Employer signature
Date
ADM 4303 (Rev. 12/2018)
DISTRIBUTION: File / MCO / BWC /TPA / Employee
Page 2 of 2
Injury / Illness Report
Employee Name: _________________________
Supplemental Statement (completed by Supervisor
and Safety & Health Coordinator)
BWC Claim #:
_________________________
Supervisor Statement (to be completed by the Supervisor)
Date Injury reported to supervisor:
Time Injury reported to supervisor:
Contributing weather or environmental factors:
Any equipment involved? _____ Yes _____ No
If yes, please specify:
Was the employee performing his/her regular job duties? _____ Yes _____ No
If No, please explain:
Specific action taken to avoid another injury:
Will disciplinary action be initiated? _____ Yes _____ No
Please explain:
Supervisor full name:
Work phone #:
Job title:
Regular shift:
Days off:
Supervisor’s signature:
Date:
Safety & Health Statement (to be completed by the S&H Coordinator)
Fully describe the accident (What occurred, what was the injury type, what object directly harmed the employee?):
What was the employee doing immediately before the accident?:
What conclusions can be drawn?
Comments and/or recommendations to improve safety:
Is this incident PERRP recordable? ______ Yes
_____No If yes, list PERRP case number from log: ______________________
S & H Coordinator full name:
Work phone #:
Job title:
Regular shift:
Days off:
S & H Coordinator’s signature:
Date:
ADM 4303 (Rev. 12/2018)
DISTRIBUTION: File / MCO / BWC /TPA / Employee
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