Form SORM-29F "Employee's Report of Injury" - Texas

What Is Form SORM-29F?

This is a legal form that was released by the Texas State Office of Risk Management - a government authority operating within Texas. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on September 1, 2020;
  • The latest edition provided by the Texas State Office of Risk Management;
  • 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 fillable version of Form SORM-29F by clicking the link below or browse more documents and templates provided by the Texas State Office of Risk Management.

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Download Form SORM-29F "Employee's Report of Injury" - Texas

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EMPLOYEE’S REPORT OF INJURY
Dear Employee:
We received a report that you were injured in the course of your employment. To process your claim efficiently, please fill in all lines
completely and print legibly. Attach additional sheets if necessary.
Name:__________________________________________________
Social Security:___________________ Gender: ☐M ☐ F
Last
First
M.I.
Maiden
Date of Injury: __________________________________
Address: ________________________________________________
Employer:______________________________________
City: _______________________________ State:______ ZIP: ______
Job Title:_______________________________________
Primary Phone Number:____________________________________
Work Schedule: _________________________________
Secondary Phone Number: _________________________________
Email address: ___________________________________________
1) What was the exact location of the accident? Include street address if possible:
2) What was happening at the time? What was going on around you, what were you doing, what were other people doing?:
3) Briefly describe what exactly caused the injury:
4) What areas of your body were injured?
5) When and to whom did you report your injury?
Date__________________________ Time________________________
Name: _________________________________ Title__________________________ Phone Number: ____________________
6) List all known witnesses (continue on back if necessary): 1. Name _______________________ Phone:_________________
2. Name ________________________ Phone: ____________ 3. Name:_______________________ Phone:________________
7) Who is your Primary Care Physician or family doctor? Name:_________________________________ Phone: ______________
8) Please list the names and phone numbers of all doctors or treatment providers you have seen for your injury:
Name:________________________________________________
Phone: ______________________________________
Name:________________________________________________
Phone: ______________________________________
Name:________________________________________________
Phone: ______________________________________
9) Has a doctor taken you off work? ☐ Yes ☐ No
If Yes, when was the first day you missed work?______________________
10) If the doctor took you off of work, have you returned to work? ☐ Yes ☐ No
If No, when do you think you will return
to work?_________________________________
11) Date of Last Appointment: __________________________ Date of Next Appointment: _________________________
12) Have you had previous workers compensation injuries? ☐ Yes ☐ No
If Yes, please enter injury dates and body
parts injured:
By affixing my signature, I attest that all information on this form is accurate and true:
Signature:_____________________________________________________
Date:________________________
SORM-29f Rev 09/2020
EMPLOYEE’S REPORT OF INJURY
Dear Employee:
We received a report that you were injured in the course of your employment. To process your claim efficiently, please fill in all lines
completely and print legibly. Attach additional sheets if necessary.
Name:__________________________________________________
Social Security:___________________ Gender: ☐M ☐ F
Last
First
M.I.
Maiden
Date of Injury: __________________________________
Address: ________________________________________________
Employer:______________________________________
City: _______________________________ State:______ ZIP: ______
Job Title:_______________________________________
Primary Phone Number:____________________________________
Work Schedule: _________________________________
Secondary Phone Number: _________________________________
Email address: ___________________________________________
1) What was the exact location of the accident? Include street address if possible:
2) What was happening at the time? What was going on around you, what were you doing, what were other people doing?:
3) Briefly describe what exactly caused the injury:
4) What areas of your body were injured?
5) When and to whom did you report your injury?
Date__________________________ Time________________________
Name: _________________________________ Title__________________________ Phone Number: ____________________
6) List all known witnesses (continue on back if necessary): 1. Name _______________________ Phone:_________________
2. Name ________________________ Phone: ____________ 3. Name:_______________________ Phone:________________
7) Who is your Primary Care Physician or family doctor? Name:_________________________________ Phone: ______________
8) Please list the names and phone numbers of all doctors or treatment providers you have seen for your injury:
Name:________________________________________________
Phone: ______________________________________
Name:________________________________________________
Phone: ______________________________________
Name:________________________________________________
Phone: ______________________________________
9) Has a doctor taken you off work? ☐ Yes ☐ No
If Yes, when was the first day you missed work?______________________
10) If the doctor took you off of work, have you returned to work? ☐ Yes ☐ No
If No, when do you think you will return
to work?_________________________________
11) Date of Last Appointment: __________________________ Date of Next Appointment: _________________________
12) Have you had previous workers compensation injuries? ☐ Yes ☐ No
If Yes, please enter injury dates and body
parts injured:
By affixing my signature, I attest that all information on this form is accurate and true:
Signature:_____________________________________________________
Date:________________________
SORM-29f Rev 09/2020
Instructions
Employee’s Report of Injury
Purpose of Form:
The injured employee completes this form to provide the State Office of Risk Management (SORM) with information
pertaining to the circumstances surrounding the injury and what has happened since the date of injury in order to
help expedite benefits.
Filing Deadline:
The form must be received by SORM not later than the 5th calendar day after the First Report of Injury or Illness
Form (DWC-1S) is reported by the agency.
Completed by:
This form shall be completed by the injured employee with assistance from the Claims Coordinator, if needed.
Instructions:
1. The employee will address each of the questions completely and use additional pages if necessary. The adjuster needs a
complete picture of the events surrounding the injury and how the injury occurred. Witnesses’ names and phone numbers,
physicians/treatment provider’s names and phone numbers and work status is needed. The employee should enter any
previous workers compensation claims information including body parts injured.
2. The injured employee will sign and date the form thereby attesting that all information on the form is true and complete.
Distribution
The Claims Coordinator shall retain the original for the agency file and fax or mail a copy to:
State Office of Risk Management
P.O. Box 13777
Austin, TX 78711
Fax: (512) 370-9025
Notice: With few exceptions, an individual is entitled, upon request, to be informed about the information a state governmental body collects about the individual.
Under Sections 552.021 and 552.023 of the Government Code the individual is entitled to receive and review the information and under Section 559.004 of the
Government Code the individual is entitled to have the state governmental body correct any information about the individual that is incorrect.
SORM-29f Rev 09/2020
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