J
Accident or Illness Report FOR OFFICE USE ONLY
Employee Statement Date Received:
Please read insfructions on back of form before completing
PERSONAL INFORMATION
Employee’s Name Social Security Number
I
Address Street City State Zip
Telephone Home Work Agency
Date of Birth Age Sex Job Title
INCIDENT REPORT INFORMATION-cy”’ “.’ “” “‘_ ‘.’ ” “. ““” w
Datemime of Injury Date/Time Reported
Reported to: Name Title Phone Number
EMPLOYEE ACCIDENT DESCRIPTION
Give cause, location of accident, how it occurred and what you were doing
Indicate body part affected and the illness or injury resulting from the incident
I On-site medical treatment sought/rendered? From:
_ Y e s _No
i Obsen/ations/Assessment:
Outside medical treatment sought/rendered?
_ Y e s _No
If yes, please provide name and phone number of provider (may be doctor, hospital, clinic, etc)
Pursuant to O.R.C. Sec. 2921.13, “No person shall knowingly make a false statement...with purpose to secure the paymerit of uorkers’ cc,nlpensatic,rl...”
I am applying for recognition of my claim under the Ohio Workers’ Compensation Act fbr work-related injuries that I did not purposeftllly inflict. I quest
pqmcnt for compensation and/or medical expenses as allowable. Direct payment(y) to the providers of any medical services are authorixd. 1 understand
Lhat I am ali~~wing any provider that attends to, treats or examines me to release all medical, psychological, an&or psychiatric infbwatiw Ul;l1 is
teiated to my workers’ compensation claim to the Ohio Bureau of Workers’ Compensation, the Ohio Industrial Commission, MS, employing agency
BIG their authorized representative(s). 1 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 a5 the original.
Signature Date
OtSTRIBUTION: White - DAS (Workers’ Comp section) / Canary - Agency / Pink - Employee / Goldenrod - Physician
ADM 4303 (Rev. H/97)
page 1 of 2
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EMPLOYEE: CLAIM NO:
EMPLOYER: DATE OF INJURY:
S.S.N.:
CALENDAR OF WAGES PAID
FOR THE PERIOD OF:
SUNDAY MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY
4 4 l ,
DATE EMPLOYEE RETURNED TO WORK:
HAS EMPLOYEE APPLIED FOR DISABILITY?
KEY: R--REGULAR DAY OFF A---ABSENT, NO PAY
S--SICK LEAVE ADM-ADMINISTRATIVE LEAVE
V--VACATION LOA-LEAVE OF ABSENCE, NO PAY
H--HOLIDAY CT-COMPENSATORY TIME
IP-INJURY PAY PL-PERSONAL LEAVE
ON THE CALENDAR ABOVE, START WITH THE DATE OF INJURY AND INDICATE THE
TYPE OF LEAVE USED ON EACH DAY.
SIGNATURE OF PREPARER PHONE NUMBER
RETURN TO: DEPARTMENT OF ADMINISTRATIVE SERVICES
BUREAU OF INSURANCE AND RISK MANAGEMENT
30 EAST BROAD STREET, ROOM 2952
COLUMBUS, OHIO 43215
RETURN WITHIN TEN (10) DAYS
ADM 4741
WAGE STATEMENT
INSTRUCTIONS: This Wage Statement should be completed and signed by the employer unless the injured worker is self-employed or unemployed. If the
injured worker is self-employed or unemployed, both the Wage Statement and the affidavit must be completed.
FAILURE TO FILE WAGE STATEMENTS MAY DELAY OR STOP COMPENSATION.
. Date of injury Claim number
Injured Worker’s name
Employer name Telephone number
If you are applying for Wage Loss benefits, please include FROM and TO dates.
FROM TO
If employee was employed continuously and/or 7 days prior to date of injury - answer 1 & 2. If employed less than 7 days prior to date of injury - answer 3 & 4.
l-Total gross wages for 6 weeks 2. Total gross wages for first 7 days 3. Employee’s hourly rate of pay the 4.Number of hours employee was
prior to injury, INCLUDE overtime prior to injury, EXCLUDE overtime week injury occurred scheduled to work, week of injury
The following worksheet is used to report the employee’s WEEKLY WAGE for the year immediately prior to the date of injury. Use total gross earnings. Make
no deductions for Social Security, Pensions, Insurance, Unemployment, etc. BWC must have an entire year to compute the rate of compensation.
If the employee did
.__I___ z__-z-- not work during any period, state reason(s) below-(Personal, plant shutdown, other injury, illness, etc.)
- -. . ,
Amount # of Days For Week Ending Amount # of Days For Week Ending Amount # of Days
For Week Ending
Earned Worked Earned Worked Earned Worked
-- -------_-~-
--_____-
--. _--- -_-__ i_l__
-__l_l
l____ll_l
.-l__l___
___-I__-_____
____-
FOR SELF-INSURING USE ONLY
FWW AWW
If employee received meals, lodging, tips, etc. in addition to wages, DESCRIBE AND STATE WEEKLY VALUE.
Will employee receive any wages, meals, lodging, health and accident insurance benefits or any other employee benefits during period of disability which are
fully paid for by the employer? . . . Cl Yes 0 No If yes, indicate period(s) and amount(s).
x
Employer Signature and Title
AFFIDAVIT
STATE OF OHIO COUNTY OF ______-_--ss: -~~~~ _ _ _ _ ~ being first duly
sworn, says that the entire earnings from -~~-~- to --~-- 19 ; as listed above is correct.
If unable to write, mark must be witnessed by two persons.
Signature of Applicant
Sworn to before me, and subscribed in my presence --- day of ----~-~~~_~_ 19 -~ .
BWC-1217 (Rev. 9/2/ 1 997)
C-94-A Official Title
COVERAGE FOR WORKERS' COMPENSATION WAITING PERIOD
ARTICLE 34.02 - APSCME/OCSEA
Employee Name:
Social Security Number:
-rr
Date of Injury:
Employer:
The AFSCME/OCSEA Contract, Article 34.02 indicates an employee
shall be allowed full pay during the first seven consecutive days ’
of absence. In order that this payment be made, the acknowledged
dates involved are:
Date
Day
Leave
Type
for a total of hours.
Completed by: Date:
II ( ) understand I will be paid for
my first seven consecutive days of absence as indicated above. I
further understand that I may not receive compensation from the
In the
Ohio Bureau of Workers' Compensation over this period.
event that a Workers' Compensation award is made for all or any
part of this period, I agree to reimburse the S,"'A",tz&"e"';"4 $r
payment received over the period above pursuant l l
Employee's Signature Date
Remarks:
cc: Payroll
DAS
(WC7-40)
.
SS#:
WAGE ADVANCEMENT AGREEMENT
This agreement is made between the State of Ohio, the Agency of the Ohio Department of
Natural Resources and the Employee
and provides the following:
The Employee has filed an application with the Bureau of Worker’s Compensation for lost time benefits as
a result of an injury received on , 19 in the course of and
arising out of the employee’s employment. The Employee has filed a request with the Agency to use paid leave
for absences occurring during the period of time required for claim approval from Worker’s Compensation.
For purposes of this agreement, paid leave is defined as accrued sick leave and any other paid leave which
the Employee may use in lieu of sick leave.
The Agency agrees to pay an advancement of wages, not to exceed the Employee’s accrued leave balances
up to a maximum of twelve (12) weeks following the date of injury. Such advancement is made in order to provide
the Employee with the necessities of life.
When the Employee is paid lost time benefits from Worker’s Compensation, the Employee promises to
repay directly to the Agency all monies received by the Employee from the Bureau of Worker’s Compensation for
the same period of time for which wages were advanced. The Employee will not be responsible to reimburse to
the Agency an amount higher than the Worker’s Compensation amount received. However, the Employee may,
at their option, purchase up to the amount of leave used while awaiting the processing of the claim.
Upon repayment, the Agency agrees to restore paid leave balances that were used pending the claim
approval up to the nearest one (1) hour increment for as many hours as repayment will restore. Sick leave will be
restored first. The Employee shall notify the Agency of other types of paid leave to be restored if more than one
type of paid leave has been used. The Employee may not have restored to any leave type an amount more than
amount used during the period of advancement. The Agency will only restore vacation leave used in lieu of sick
leave during the period of advancement; vacation leave used for vacation is not restorable.
The Agency shall notify the Employee when payment by Worker’s Compensation is sent to the Agency
directly. If the Employee receives payment from Worker’s Compensation, the Employee will repay the
advancement within two pay periods of receipt of payment.
(Cont’d)
Agreement
Page 2
If repayment is not made within the time limit above, the following action may be taken without further
notice to the Employee: _
a. The Agency may begin taking deductions from the Employee’s check and remaining leave
balances to satisfy the amount owed.
b . The Agency may notify Worker’s Compensation that the amount of benefits paid to the
Employee was excessive because of income paid to the Employee for the same weeks for
which full benefits were paid as sick leave.
c. Action may be initiated by the Office of the Attorney General to recover the monies
advanced by the Agency. If this becomes necessary, the Employee agrees to pay
reasonable attorney fees, interest and court costs incurred in the course of recovering
the overpayment.
This agreement shall be governed by the law of the State of Ohio and the Collective Bargaining Agreement
covering Agency and Employee, and it is made with the expressed understanding that if the Employee receives
final order from the Industrial Commission denying the Worker’s Compensation claim, this agreement is null and
void, relieving the Employee of any obligation for repayment of advanced wages and the Agency of any obligation
to restore paid leave used. If entitlement to weekly wage benefits is approved, this agreement shall be the authority
for the Bureau of Worker’s Compensation to send all warrants for lost time wages for the period of advancement
to the Employee in care of the Agency.
@ate) (Employee Signature)
(Agency Representative Signature)
Ohio Dept. of Natural Resources
(Agency Name)
1930 Belcher Drive, Bldg. D-l
Columbus, OH 4322401387
(Agency Address)
This new Request for Temporary Total Compensation (C-84) Application replaces the Physician’s Supplemental Report previously
used as medical evidence to support continued temporary total disability benefits.
The old application was completed and signed by the physician of record. This new C-84 asks the injured worker to complete Items
I-6 and sign on the front of the form. The physician of record completes Items 7-I 2 (along with the injured worker’s name and claim
number), and must provide their signature in item 13. In addition, both parties are notified that “Any person who knowingly makes
a false statement, misrepresentation, concealment of fact, or any other act of fraud to obtain payment as provided by BWC, or who
knowingly accepts payment to which that person is not entitled is subject to a felony criminal prosecution and may, under appropriate
criminal provisions, be punished by a fine or imprisonment or both.”
It is the injured worker’s responsibility to file this form with BWC. If the injured worker’s employer is self-insuring, the injured worker
must file this form with that self-insuring employer.
ITEM 1 Provide information that is up to date and accurate. The address provided will be used to mail all correspondence from
BWC to you, including your compensation checks. A telephone number is helpful if we need to contact you for additional
information.
ITEM 2 Dates off work due to current period of work-related disability: List the most recent dates you were off work because
of your work related disability.
Last date worked: Give the last day you worked for any employer, including yourself.
Return to work date: If you returned to work, give the date you went back to work. If you have not returned to work,
leave this blank.
ITEM 3 Employer name (where injury/disease happened): Give the name of your employer at the time of your injury. is light
duty or modified work available with this employer? Does your employer have any light duty or modified work available
within your physical capabilities? If you don’t know, check the box.
ITEM 4 Have you worked, in any capacity, (include full-time, part-time, self-employment or commission work) during
the disability period shown above?: Have you performed any work for any employer, including yourself, during the
disability period listed in item 2? Please give accurate and complete information if you answered yes to item 2.
ITEM 5 Have you received or filed for any of the following benefits since your injury?: Indicate if you have received any
of the listed benefits because of your injury. Provide claim numbers or dates if you answer yes to any of the benefits
on the list. This does not include your personal/group medical insurance for non-work related conditions.
ITEM 6 Injured worker signature: Please sign and date this form when requesting temporary total disability compensation.
If you cannot sign, mark the form in the presence of two witnesses. Signing the form means that you have answered
the questions as truthfully and completely as possible. It also means that you are aware that providing false information
or concealing information to obtain compensation may subject you to felony criminal prosecution, and may be punished
w
by a fine or imprisonment or both.
Instructions for the physician are on the back
This new Request for Temporary Total Compensation (C-84) Application replaces the Physician’s Suppiemental Report previousiv
d
used as medical evidence to support continued temporary total disability benefits.
The old aoplication was compieted and signed by the physician of record. This new C-84 asks the injured worker to complete Items
I-6 and sign on the front of the form. The physician of record completes Items 7-12 (along with the injured worker’s name and claim
number), and must provide their signature in Item 13. In addition, both parties are notified that “Any person who knowingly makes
a false statement, misrepresentation, concealment of fact, or any other act of fraud to obtain payment as provided by RWC, or who
knowingly accepts payment to which that person is not entitled is subject to a felony criminal prosecution and may, under appropriate
criminal provisions, be punished by a fine or imprisonment or both.”
It is the injured worker’s responsibility to file this form with BWC. If the injured worker’s employer is self-insuring, the injured worker
must file this form with that self-insuring employer.
!TEM 1 Provide information that is up to date and accurate. The address provided will be used to mail all correspondence from
BWC to you, including your compensation checks. A telephone number is helpful if we need to contact you for additional
information.
ITEM 2 Dates off work due to current period of work-reiated disability: List the most recent dates you were off work because
of your work related disability.
Last date worked: Give the last day you worked for any employer, including yourself.
Return to work date: If you returned to work, give the date you went back to work. If you have not returned to work.
leave this blank.
ITEM 3 Employer name (where injury/disease happened): Give the name of your empioyer at the time of your injury. Is light
duty or modified work available with this employer? Does your employer have any light duty or modified work available
within your physical capabilities? If you don’t know, check the box.
lTEM 4 Have you worked, in any capacity, (include full-time, part-time, self-employment or commission work) during
the disability period shown above?: Have you pet-formed anv work for any employer, including yourself, during the
disability period listed in item 27. Please give accurate and complete information if you ans\+iereti yes to item 2.
ITEM 5 Have you received or filed for any of the following benefits since your injury?: Micz,te if Ivou have rxeived at-x
i>i the listed benefits because of your injury. Provide claim numpers or dates if you answer :/es to any of the benefits
on the list. This does not include your personaligrotip mediczi insurance for non-work i-e&ted conditions.
iTEM 6 Injured worker signature: PQse sign and date this icrm ‘;Jnen requestinc temf’orarv ICIZI rjkabilitv compensalkx.
. _+
if you cannot sign, alark the form in ihe presence oi two witnesses. Signin&he form means rhat yoi have answer-es
rhe questions as truthfully anrl completely as possible. it also means that vci are aware thai Droviding false information
or concealing information to obtain compensation may subjec t ;;ou to feionv criminal prcsestitlcn. and may be p;lnishe:. ,. :. ,.
x:_:: _ ;; I:i~~_g‘;_~.,
F
._.:;:
‘.:.:.,.>
.:.y*::
:.::.i’ .:: ::.
.:. . . :_ ., ,. . .:
., .,. .:. :.y
1
1 Address City State g-digit ZIP Code
-
IIates off work due to current period of work related disability: Last date worked: Return to work date:
2
-
I Employer name (where injury/disease happened) Is modified (or tight) duty work available with
3
this employer? 3 Yes [7 No 0 Don’t know
-
Have you worked, in any capacity, (include full-time, part-time, self-employment or commission work) during the disability period shown above?
Cl Yes Cl No If yes, provide employer name:
Employer name (self, if self-employed) Telephone number
4
( )
Address City State g-digit ZIP Code
- I 1 1
Have you received or filed for any of the following benefits since your injury?
Unemployment compensation . . . . . . . . . . . . . . . 0 Yes q No OBES claim number
Social Security retirement . . . . . . . . . . . . . . . . . . . . . 0 Yes 0 No Social Security claim number
Sick leave . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Yes 0 No From to
5
Public Assistance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . c] Yes 0 No Human Services case number
Wage continuation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...*
0 Yes 0 No From to
Have you applied for or are you receiving other benefits from any other source regarding this injury? q Yes NO
If yes, give Agency/Company name Claim number
M...>...., v : :.
::_‘:. .y..i:;.: ::
:‘.‘:.“:;..:y.p.;x.x
;.;_,: ..>::z.:p‘..’“;
d
I certify that the above information is correct to the best of my knowledge. I am aware that any person who knowingly
makes a false statement, misrepresentation, concealment of fact or any other act of fraud to obtain payment as provided
by BWC or who knowingly accepts payment to which that person is not entitled is subject to felony criminal prosecution
and may, under appropriate criminal provisions, be punished by a fine or imprisonment or both.
Physician of record name BWC provider number-
mandatory
13
I
1Address City State g-digit ZIP Code Telephone number
( )
Physician of record signature Date
-
-
Application For Disability Leave Benefits
Employer Statement
The employer shall within five (5) days of receipt of the claim forward the claim and the claim recommendation to the Department of
Administrative Services, Disability Section, 30 East Broad Street, Columbus, Ohio 43266-0405. Please notify the Disability Section when
you learn of any unexpected return to work or other change in employee’s status.
Please Complete AU Questions
Employees Name (print or type) Application is for:
Agency Payroll Number c] Initial Claim 0 Reinstatement of Benefits
[7 Extension of Benefits 0 Part-time Benefits
EMPLOYEE HISTORY
Has employee completed one year of continuous state service at any time? Date employee last worked
[7 Yes 0 No i I19
Has employee returned to work? If yes, give date of return Did employee work at all between the dates
Cl Yes 0 No / I19 previously listed? q Yes c] No
If yes, give dates and explanation
Is employee: For bargaining units which provide coverage for part-time employees, please indicate the
number of hours employee worked in the 12 months preceding disability.
0 full-time q part-time
Is employee being placed on approved leave for If Yes, give dates of approved leave
medical reasons? q Yes 0 No
If No, provide explanation
Is employee being placed on administrative leave? If Yes, give dates of leave:
c] Yes 0 No
JOB DUTIES
Employees Classification Classification Number PCN
Does the agency provide light duty/non-stressful work?
q Yes cl No
Comment:
RETURN TO WORK ON A PART-TIME BASIS: Please complete this section if appkation is for part-time benefits.
Indicate approval or disapproval of part-time work:
If disapproved, employee should not be allowed to work on a part-time basis.
If disapproved, daim will be reviewed to determine employee’s eligibility for full-time benefits.
c] Approval q Disapproval
Employee’s part-time schedule : Dates of part-time work:
Days per week Hours per day
*PI&me not@ the Disability Section if part-time work is discontinued,
DISTRIBUTION: White - DAS (Disability Section) / Canary - Agency
ADM 4312 (Rev. 10192)
(Previously TO31 ) page 1 of 2
- .-. - ‘-“4 -b.,.i Sr- -__.- -4 --‘ -We - .-N c’
61531
Employee’s Name 1 Social Security Number
WORK RELATED CLAIMS
If this is an initial BWC illness/injury, you are responsible for attaching the original and two (2) copies of the employee’s application for lost time wages and
three (3) original wage agreements to this application. THE BWC APPLICATION AND DISABILITY APPLICATION SHOULD NEVER BE SEPARATED.
I If claim is work related, please provide date of original injury Are you aware of other claims filed with BWC that may be related to this injury?
If Yes, please provide BWC claim number(s) and date(s) of illness/injury(s)
0 Yes 0 No
I Are you aware of any payment by BWC for this illness/injury? 0 Yes 0 No
PHYSICIAN REVIEW
If you feel this claim should be reviewed by a physician, please mark this block. 0 If checked, please forward a copy of the position description.
1 AGENCY RECOMMENDATION:
One block must be checked. It is not necessary to recommend approval or disapproval on extension requests. u Approval u Disapproval u Extension
Reasons (Attach separate sheet, if necessary)
I
Agency Contact (print or type) Area Code/Telephone
Appointing Authority or Designee Signature Date
DISTRIBUTION: White - DAS (Disability Section) / Canary - Agency
ADM 4312 (Rev. 10/‘92) _
(Previously TO31 ) page 2 of 2
Application for Disability Leave Benefits PERSONNEL OFFICE USE ONLY
Date Employee’s Statement Received in Office
Employee Statement (Date Stamp Preferred)
Please read instructions on back of vage 4 of this
form before comvletinn avvlication
Section I - Personal Data
Employee’s Name Social Security Number
Address Street City State Zip
Telephone Home Work Agency Classification
Section II - HISTORY OF DISABLING CONDITION
Date accident or illness began Date became disabled because of Date last worked Date of first treatment
accident or illness
/ / 19 / / 19 / / 19 I /19
Date of most recent treatment Date of next appointment with physician
/ / 19 I I19
Section Ill - NATURE OF DISABLING CONDITION
Describe your disability
Was disability due to an injury? If yes, date of injury How and where did accident happen?
C] Yes •] No I I19
Was injury or illness caused by or resulting from an act of war?
0 Yes 0 No
Name(s), address(s), and telephone number(s) of all physicians treating you for this condition
Name Address Phone
Have you been hospitalized for this illness? If yes, give name of hospital and city Date(s) of confinement
r’~ Yes q No IN I I19 OUT / /19
Additional hospitalizations/dates
DISTRIBUTION: White - DAS (Disability Section) / Canary - Agency / Pink - Employee / Goldenrod - Physician
ADM 4310(Rev.9/97)
page 1 of 4
Employee’s Name Social Security Number
Section IV - WORK RELATED CLAIMS - PLEASE READ INSTRUCTIONS ON BACK OF PAGE 4
Have you ever applied for workers’ compensation benefits involving the same part of body as your current illness/injury or for a condition in any way
related to your current illness/injury? q No 0 Yes If Yes, provide
BWC Claim Number(s)
z
Date(s) of illness/injury(s)
Is your current illness/injury a reoccurrence of a previous illness/injury If Yes, did you receive any lost time wages from BWC?
listed above?
0 Yes. 0 No 0 Yes q No
Was your current illness/injury received in the course of and arising out of your employment with the State of Ohio and/or any other employer?
0 Yes cl No If Yes, read and complete the rest of this section.
Have you filed a BWC claim for your current condition? Are you filing a BWC claim for your current condition?
0 Yes 0 No q Yes c l No
Section V - OTHER BENEFITS
Do you receive retirement or disability benefits from a State Employees’ -Retirement system?
0 Yes cl No
If Yes, please attach an explanation of benefits received and dates.
Section Vi - RETURN TO WORK
Have you returned to work? If Yes, give date If No, what date do you expect to return?
Are you returning to work part-time and applying for disability 1 Have you engaged in any occupation for wage or profit since
benefits on a part-time basis? the onset of your disability?
0 Yes 0 No 0 Yes q No
Place of employment Provide dates worked
Section Vii - SUPPLEMENTATION
Do you wish to supplement disability by utilizing available leave time?
0 Yes III No
Section Viii - EMPLOYEE CERTiFiCATiON/AUTHORlZATiON FOR RELEASE OF INFORMATION
I hereby authorize any hospital or clinic, physician, nurse or practitioner, including Employee Assistance Program (EAP), and or the retirement
system which I participate in or any other person involved with my claim for disabiity leave benefits to provide the Department of Administrative
Services and other state agencies involved with my claim for disability benefits with complete information as to my health and medical history,
eligibility for Disability Retirement Benefits and any information required in connection with this claim, hereby waiving any and all privileged
character of such information. I also hereby authorize the Department of Administrative Services to release any such information it receives to
other state agencies involved with my claim for disability benefits. I understand other state agencies may contact me regarding their services in
assisting me to return to work. A photocopy of this authorization shall be as valid as the original.
I understand that it is my responsibility under ADA to contact my employer if I wish to apply for reasonable accommodations under ADA or to
obtain information about my right under ADA.
I have read and understand the instructions on the back paqe 4 of this application. I certify that the above statements are true to the best of my
knowledge and understand any misrepresentation on my part may result in a denial of my benefits.
Date Employee’s Signature
Please Note: Employee is responsible for returning all 4 pages of this form to employing
agency. Claim information submitted directly to the Disability unit will be forwarded to the
employee’s personnel office. The personnel office is required to keep all information about the
nature of the illness confidential.
DISTRIBUTION: White - DAS (Disability Section) / Canary - Agency / Pink - Employee / Goldenrod - Physician
ADM 4310 (Rev. 9/97)
page 2 of 4
Attending Physician Statement
(Physician insfrucfions for completing this form are in the lasf section on the back of page 4
Employee’s Name Social Security Number
I
Section IX - HISTORY OF CURRENT CONDITION(S)
Date you rendered this patient disabled
Ever had same or similar condition: If Yes, state when and describe
0 Yes 0 No
Date first consulted you for this condition Additional dates of treatment including the most recent visit
Frequency of visits Is condition due to injury or sickness arising out of employment?
0 Weekly
q Monthly q Yes 0 No
0 Other (specify)
Section X - DIAGNOSIS
Give complete diagnosis including ICD-9 Code
Describe fully any complications
Section Xl - PREGNANCY
If condition is due to pregnancy, what was/is expected delivery date? MO Day 19-
Give dates of and describe fully any complications prior to delivery
Section XII - PSYCHIATRIC CONDITION *PLEASE COMPLETE IN DETAIL*
Describe mood and affect, ability to relate, ability to carry out daily activities, follow instructions, judgment, and ability to concentrate
Is there evidence of a thought disorder or impairment in memory? 0 Yes c] No
Please comment
Comment on how the combined symptoms and intensity interfere with job performance
DISTRIBUTION: White - DAS (Disability Section) / Canary - Agency / Pink - Employee / Goldenrod - Physician
9DM 4310 (Rev. 9/97)
page 3 of 4
Employee’s Name Social Security Number
Section XIII - PRESENT CONDITION
Subjective symptoms (describe fully)
Objective findings. List all pertinent findings and attach available medical evidence to support claim. Insufficient evidence may result in disapproval.
(Include results of any pertinent testing: X-rays, EKG’s, blood pressure readings, neurological testing, MMPI, mental status reports and any findings on
physical exam to include height and weight.
List medications currently prescribed.
Was patient hospitalized? If yes, name of hospital
0 Yes ON 0
Date of hospitalization Reason for hospitalization and/or type of surgery
If surgery performed, give date If off work prior to surgery, comment on problems prior to surgery.
MO Day 19-
Section XIV - PROGRESS
Do you expect marked change in the future? 0 Yes q No Comment as to nature of continuing treatment and progress
Patient’s disability is: 0 Temporary 0 Expected to last longer than 12 months 0 Permanent
If disability is temporary, patient’s estimated date of release to return to work:
0 For regular occupation MO Day , 19-
0 For work on a part-time basis, if approved by patient’s agency MO Day 19-
part-time schedule: hours per day days per week
0 For suitable work activities within the limitations listed below. MO Day 19-
What restrictions are placed on patient’s work activities?
Section XV - REMARKS
Additional Remarks:
Section XVI - PHYSICIAN SIGNATURE
Name (attending physician) Please print Specialty Fed ID# Telephone
Street Address City or Town State Zip Code
Date form received Date Signed
Signature
DISTRIBUTION: White - DAS (Disability Section) / Canary - Agency / Pink - Employee / Goldenrod - Physician
ADM 4310 (Rev. 9/97)
page 4 of 4
Supplemental Report: Personnel Office Use Only
Date Form Received in Your Office
Disability Leave Benefits (Date Stamp Preferred)
Employee Statement
Please read instructions on back of form
before completing application
Section I - PERSONAL DATA
Employee’s Name (Print or Type) (Last) ( First) ( Middle) Social Security Number Claim Number
Address street City State Zip
Work Telephone Number Home Telephone Number
Section ii - HISTORY OF DISABLING CONDITION
Have there been any changes in your condition since If Yes, please explain.
your original claim? q Yes c) No
Have you been hospitalized since your original claim? If Yes, give dates of confinement:
q Yes q No
Name of Hospital Reason for Confinement
Section iii - RETURN TO WORK L
Have you returned to work? If Yes, give date: If No, what date do you expect to return?
q Yes q No
Are you returning to work part-time and applying for disability Have you engaged in any occupation for wage or
benefits on a part-time basis? profit since the onset of your disability?
c] Yes 0 No q Yes q No
If Yes, did you receive compensation? Provide dates worked:
fl Yes q No
Place of Employment:
Section IV - WORK RELATED CLAIMS
For Claims Paid As An Advancement of Workers’ Compensation Benefits:
Have you received a lost time claim number from BWC? If Yes, please provide number
q Yes q No Have you received lost time wages from BWC? q Yes q No
If your claim was not as an advancement of workers’ compensation, have any conditions become
disabling that were caused by or resulting from your job? q Yes q No
If Yes, please describe
Section V- EMPLOYEE CERTiFiCATiON/AUTHORiZATiON
I hereby authorize any hospital or clinic, physician, nurse or practitioner, including Employee Assistance Program (EAP), and or the retirement
system which I participate in or any other person involved with my claim for disabiity leave benefits to provide the Department of Administrative
Services and other state agencies involved with my claim for disability benefits with complete information as to my health and medical history,
eligibility for Disability Retirement Benefits and any information required in connection with this claim, hereby waiving any and all privileged
character of such information. I also hereby authorize the Department of Administrative Services to release any such information it receives to
other state agencies involved with my claim for disability benefits. I understand other state agencies may contact me regarding their services in
assisting me to return to work. A photocopy of this authorization shall be as valid as the original.
I understand that it is my responsibility under ADA to contact my employer if I wish to apply for reasonable accommodations under ADA or to
obtain information about my rights under ADA.
I have read and understand the instructions on the ‘back of paae 2 of this application. I certify that the above statements are true to the best of
my knowledge and understand any misrepresentation on my part may result in a denial of my benefits.
Date Employee’s Signature
Please Note: Employee is responsible for returning both pages of this form to employing
agency. Claim information submitted directly to the Disability unit will be forwarded to the
employee’s personnel office. The personnel office is required to keep all information about the
nature of the illness confidential.
DISTRIBUTION: White - DAS (Disability Section) / Canary - Agency / Pink - Employee / Goldenrod - Physician
ADM 4311 (Rev. U/97) paQe 1 of 2
S 33102 :
,I
‘_&’ :&. *:._&
Attending Physician Statement
(Physicians instructions for completing form are in the last section on the back of this form)
Employee’s Name Social Security Number
Section VI - DIAGNOSIS
Give complete diagnosis
All treatment dates since last report Date of next appointment:
Section VII - PRESENT CONDITION
Subjective symptoms (describe fully)
Objective findings: Attach available medical evidence to support claim. Insufficient evidence may result in disapproval. (Include results of any
pertinent testing: X-rays, EKG’s, blood pressure readings, neurological testing, MMPI, mental status reports and any findings on physical exam to include
height and weight).
List any change in medications since onset of disability.
Has patient been hospitalized since initial claim? 0 Yes O N0 Dates of confinement:
Reason for confinement: Name of hospital:
.
If surgery performed, give date and type of surgery
Section VIII - PROGRESS
Has normal recovery been delayed? Cl Yes ON 0
Describe fully any complications
Comment as to nature of continuing treatment. Do you expect marked change in the future? 0 Yes 0 No
If Yes, comment.
Patient’s disability is: 0 Temporary 0 Expected to last longer than 12 months 0 Permanent
If disability is’ temporary, patient’s estimated date of release to return to work:
0 For regular occupation MO Day 19-
0 For work on a part-time basis, if approved by patient’s agency MO Day 19-
part-time schedule: hours per day days per week
0 For suitable work activities within the limitations listed below. MO Day 19-
Section IX - REMARKS
Section X - PHYSICIAN SIGNATURE
Name (attending physician) Please Print Specialty Federal I D# Telephone
I I
Street Address City State Zip
Date Form Received Date Signed Signature
DISTRIBUTION: White - DAS (Disability Section) / Canary - Agency / Pink - Employee / Goldenrod - Physician
ADM 4311 (Rev. 12197) page 2 of 2
:
L r’
Instructions: Three originals of this form must be submitted whenever you file for disability as an advancement of
Workers’ Compensation. Photocopies cannot be accepted. All blanks must be completed. Alteration of this form or
failure to fill in all blanks may result in the form being returned to you. This will cause a delay in the processing of
your claim.
NAME SOCIAL SECURITY NO.
On the day of 19 ~ , at
Ohio, in the County of this agreement between the State of Ohio,
the Department of Administrative Services, Office of Benefits Administration, Disability section
hereafter referred to as DAS, and , Employee, was executed
under the following terms and conditions:
Employee has filed an application for disability leave benefits for disability resulting from an injury
or illness received on 19~. Except for those employees
filing for purposes of confidentiality directly with the Disability section of the DAS, Employee has
simultaneously filed, with the Employee’s agency, a claim for Bureau of Workers’ Compensation Lost
Time Wages and a claim for disability leave benefits.
DAS agrees to pay a reimbursable advancement of disability leave benefits in order to provide
Employee with the necessities of life, in consideration for which Employee agrees to reimburse DAS for
the amounts so advanced. Employee also understands that it is Employee’s responsibility to keep DAS
notified of the status of the workers’ compensation claim. Employee understands that, once an
advancement is received, it is Employee’s responsibility to continue to pursue the claim for Lost Time
Wages with the Bureau of Workers’ Compensation. Failure to pursue a workers’ compensation claim
may result in denial of an advancement or an action by DAS to recover the amount so advanced.
Upon entitlement to weekly wage payments and as consideration for the receipt of disability leave
benefits, employee promises to pay directly to the Disability Leave Benefit Program all monies
advanced by the program for the same period of disability for which employee received weekly
payments from the Bureau of Workers’ Compensation. Such repayment shall be made by employee in
a lump sum directly to the Disability Leave Benefit Program. If no lump sum payment is received within
two (2) weeks of employee being notified of such debt, deductions from employee’s pay check will be
made to satisfy the debt amount. If it becomes necessary to initiate appropriate action by the Attorney
General to recover the monies advanced by the Disability Leave Benefit Program, then employee agrees
to pay DAS reasonable attorney fees in such suit.
This agreement shall be governed by the laws of the State of Ohio and is made with the express
understanding that if employee receives a final order from the Industrial Commission denying the
Workers’ Compensation claim, this agreement is null and void. If entitlement to weekly wage benefits
is approved, this agreement shall be the authority to send all warrants for Lost Time Wages to employee
in care of DAS for no more than the first twelve (12) weeks of compensation closely following the date
of injury.
The undersigned employee has read this agreement, understands all of its terms, and has executed
such agreement voluntarily.
SIGNED:
DATE EMPLOYEE
DATE AGENCY
DATE DEPARTMENT OF ADMINISTRATIVE SERVICES
OFFICE OF BENEFITS ADMINISTRATION
DISTRIBUTION: White - DAS / Disability / White - DAS (BWC Copy) / Canary - Agency / Pink - Employee
ADM 4313 (Rev. 3/91)
q A The Industrial Commission of Ohio
This form should be delivered CLAIM NUMBER
NOTICE OF APPEAL
to the office where this decision took place.
SOCIAL SECURITY #
0 Address on appeal is new DATE OF INJURY
Injured Worker’s Address Employer’s Address
Jame Phone Name
( )
\dd ress Address
Xy, State, Zip Code County City, State, Zip Code Phone
( )
Injured Worker’s Representative’s Employer Representative’s
dame Name
Appealed by 0 Injured Worker 0 Employer 0 BWC Administrator
Appealing Order of
Heard at (City) Oh .
0 BWC Administrator
Date of Hearing:
0 District Hearing Officer
Date Order Received:
0 Staff Hearing Officer
Reason for Appeal:
How would you like the order changed:
0 Please attach copies of; BWC Administrator, District Hearing Officer, Staff Hearing
Officer order, medical reports, test result and any other supporting documents.
Do you plan to submit new evidence? Lly es ON 0
If yes, must attach new evidence when filing appeal.
To be completed by Self-Insured Employer.
0 Compensation / benefits timely paid as mandated by R.C. 4123.511
0 Compensation I benefits NOT timely paid as mandated by R.C. 4123.511
NOTE: Failure to attach the necessary documents may result in a determination not to hear an appeal
* *
at the Commission level.
I hereby certify that I have mailed copies of this notice to the 0 injured worker’s representative and / or 0 employer’s
representative (check one or both), on ,19-. If there is no representative) have mailed a copy to the
injured worker and/or employer.
(Appellant’s Signature)
OIC3000(Rev7/98)
An Equal Opportunity Employer And Service Provider