State Of Ohio PERSONNEL OFFICE USE ONLY
Date Employee's Statement Received in Office
Occupational Injury Leave Benefits
(Date Stamp Preferred)
Please read instructions on page 2 of this form before completing application
Section I - PERSONAL DATA
Employee's Name Employee ID Number
Address Street City State Zip
Telephone Home Work Agency Payroll Number Job Code Title
Section II - HISTORY OF DISABLING CONDITION
Complete all dates using the mm/dd/yyyyy format.
Date injury occurred Date became disabled Date last worked
Date of first treatment Date of most recent treatment Date of next appointment with physician
Section III - NATURE OF DISABLING CONDITION
Describe how your injury occurred. Include a description of what you were doing, how you were injured and list the names of any witnesses.
Section IV - EMPLOYEE CERTIFICATION/AUTHORIZATION
Pursuant to O.R.C. Sec. 2921.13, “No person shall knowingly make a false statement...with purpose to secure the payment of workers’ compensation...”
I am applying for recognition of my claim under the Ohio Workers' Compensation Act for work-related injuries that I did not purposefully inflict. I request
payment for compensation and/or medical expenses as allowable. Direct payment(s) to the providers of any medical services are authorized. I understand
that I am allowing any provider that attends to, treats or examines me to release all medical, psychological, and/or psychiatric information that is
related to my workers' compensation claim to the Ohio Bureau of Workers' Compensation, the Ohio Industrial Commission, DAS, employing agency
and their authorized representative(s). A photocopy of this authorization shall be as valid as the original. I have read and understand the instructions on page 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 the
denial of my benefits.
Employee's Signature Date
ADM 4743 (Rev. 12/02) Page 1 of 2
INSTRUCTIONS FOR EMPLOYEE'S APPLICATION
Occupational Injury Leave Benefits are authorized * The agency is responsible for completing all calculations
by ORC 124.381 and the bargaining unit contracts. of part-time employees and preparing calendar of
wages used on your behalf within five days of receipt
* This form is used only for an initial filing for injury of this application.
leave benefits. If you are filing supplemental
information for an extension of these benefits, you must Section III - Nature of Disabling Injury
use form ADM 4722. * You must explain in detail how you were injured.
Your explanation must make it possible to determine
Completion of Forms your eligibility.
* Employees who think they are eligible for this type * Write legibly with a pen or use typewriter (do
of leave may apply to their Agency Designee within not use pencil).
twenty (20) days of the incident giving rise to the injury
unless physically unable to do so. Section IV - Employee's Certification/Authorization
* Employee is responsible for completing Sections I This completes the portion of the application process to
through IV of this application form. be completed by the employee. Date and sign this
* This application must be accompanied by form ADM application and return forms to your employing agency
4721 (Attending Physician's Report). designee/personnel officer.
* Employee is responsible for returning this application
and supporting documentation to employing * The employing agency is required to complete
agency within twenty (20) days of the incident giving ADM 4723 (Appointing Authority Statement) and
rise to the injury unless physically unable to do so. forward this application, the Attending Physician's
* All sections of application must be completed. Report and other necessary documentation to
Failure to fully complete application may result in the CompManagement for completion
denial of benefits. of processing.
* Applications sent directly to Department of
Administrative Services (DAS) will be returned to
employing agency for completion of Appointing Forms Needed for Initial Filing Process
Statement. ADM 4743 Application for Occupational
Injury Leave, Employee
Section I - Personal Data Statement
* You must keep your agency notified of any change in
address. ADM 4723 Appointing Authority Report
* You must notify your supervisor of your absence and
your expected date for return to work. ADM 4721 Attending Physician Statement
* Your agency Payroll number must appear on this
application. ADM 4728 Part-time Employment Calculation
Report (if you are a part-time
Section II - History of Disabling Condition employee)
* The history assists in determining the beginning
date of benefits. ADM 4741 Calendar of Wages Paid Report
* Injury leave benefits are in lieu of any other benefits
over the same period. No accumulation of sick or (include all reports and witness statements available)
vacation leave credit will be granted during the period(s)
* Upon a denial of benefits, you have ten days to file a
grievance of this denial. No other appeal process is
ADM 4743 (Rev. 12/02) Page 2 of 2