DoL LS-202 2020-2025 free printable template

Date of This Report Form LS-202 Rev. Oct. 1998 This report is to be filed in duplicate with the District Director in the appropriate district office of the Office of Workers Compensation Programs and is required by 33 U.S.C. Employer s First Report of Injury or Occupational Illness U*S* Department of Labor Employment Standards Administration Office of Workers Compensation Programs See instructions on reverse - Leave items 1 and 2 blank OMB No* 1215-0031 1. OWCP No* 2. Carrier s No* 3. Date...

How to fill out ls202 form

How to fill out DoL LS-202

1. Obtain the DoL LS-202 form from the Department of Labor website or through your employer's human resources department.
2. Fill out the employer's name, address, and contact details at the top of the form.
3. Enter the date of the injury or illness in the designated section.
4. Provide the employee's information, including their name, address, and social security number.
5. Describe the nature of the injury or illness, including what happened and how it occurred.
6. Include the details of any witnesses to the incident if available.
7. Complete the sections regarding the employee's job and employment details.
8. Review the form for any missing information or errors before submission.
9. Submit the completed form to the appropriate office as indicated by the instructions provided.

Who needs DoL LS-202?

1. Employees who have sustained work-related injuries or illnesses.
2. Employers required to report workplace injuries to comply with Department of Labor regulations.
3. Insurance companies processing claims related to workplace injuries.

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Instructions and Help about employers injury report

People Also Ask about ls202 form

What is an incident report form?

An incident report form is used to provide a comprehensive record of any unwelcome or undesirable occurrence that occurs within the workplace environment. This includes such things as workplace accidents, hazardous material spills, safety violations or misconduct by employees.

How do you write an injury report example?

What should you include in an incident report? When & where did it happen? Your report should contain the date, time and location where the accident took place. Who were involved? What did they do? Why did it happen? Were there any witnesses? What is the extent of damage to a person or property?

How do you write an injury incident report?

How to create an incident report Have all basic facts prepared. In order for an incident report to be useful, it is helpful for all facts listed in the report to be specific and accurate. Explain the sequence of events step-by-step. Analyze the incident. Describe any injuries. Proofread your work. Submit your report.

What are the 4 types of incident reports?

The 4 main incident reports that should be on your list are: Near Miss Reports. Near misses are events where no one was injured, but given a slight change in timing or action, someone could have been. Injury and Lost Time Incident Report. Exposure Incident Report. Sentinel Event Report.

What is the format of writing an incident report?

Incident reports include all of the facts related to the incident, such as the contact information of the people involved; a description of the incident itself; and any follow-up actions that were taken, like medical treatment.

What is an example of an injury statement?

I am respectfully presenting this letter as written notice that I was involved in a work-related accident on [date of incident] at approximately [time of incident]. [I was injured / I became ill] when [give clear details involving the accident, including what led up to it].

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What is DoL LS-202?

DoL LS-202 is a form used by employers to report employment and wage data for certain employees in industries under the jurisdiction of the U.S. Department of Labor.

Who is required to file DoL LS-202?

Employers who are engaged in businesses covered by the Longshore and Harbor Workers' Compensation Act (LHWCA) and similar statutes are required to file DoL LS-202.

How to fill out DoL LS-202?

To fill out DoL LS-202, employers need to provide information about their employees, including wage and employment details, following the instructions provided on the form.

What is the purpose of DoL LS-202?

The purpose of DoL LS-202 is to gather data for the enforcement of laws related to workers' compensation and to ensure compliance with labor regulations.

What information must be reported on DoL LS-202?

The information that must be reported on DoL LS-202 includes the names of employees, wages earned, hours worked, and other employment-related details.