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
FOR OFFICE USEUnit
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 (Street / City / State / Zip): Social Security #:

Phone # (Home / Work): Date of Birth: Age: Sex:

Your employer’s name: Job Title: Employer’s BWC Policy #:

SUPREME COURT OF OHIO 10003101-0

Regular work hours: From ______ am/pm To ______ am/pm Work Days: ___Sun ___Mon ___Tues ___Weds ___Thurs ___Fri ___Sat

INCIDENT REPORT INFORMATION OFF WORK BENEFITS:

Date/Time of Injury: Check one benefit type:

____ Temporary Total Compensation
Were you working overtime when this injury occurred? ____ Yes ____ No
____ Salary Continuation*
Reported to (Name/Title): Date/Time Reported: ____ Occupational Injury Leave*; inflicted by a ward of the
State (inmate, patient, resident, client, youth or student)
*Must seek medical treatment from WILMAPC
approvedorprovider
Exact location of incident (Include name of building/area and location within building/area 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 (Street / City / State / Zip): Work County:

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

_____ OCCUPATIONAL INJURY LEAVE Appointing Authority Signature: __________________________________

Date: Coordinator’s initials:

Date employee became disabled:

Total hours being requested: Comments:

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
 First Report of an Injury,
Occupational Disease or Death
By signing this form, I: WARNING:
• Elect to only receive compensation and/or benefits that are provided for in this claim under Ohio workers' compensation laws; Any person who obtains compensation from
• Waive and release my right to receive compensation and benefits under the workers' compensation laws of another state for BWC or self-insuring employers by knowingly
the injury or occupational disease, or death resulting from an injury or occupational disease, for which I am filing this claim; misrepresenting or concealing facts, making false
• Agree that I have not and will not file a claim in another state for the injury or occupational disease or death resulting from an statements or accepting compensation to which he
injury or occupational disease for which I am filing this claim; or she is not entitled, is subject to felony criminal
• Confirm that I have not received compensation and/or benefits under the workers’ compensation laws of another state for this claim, prosecution for fraud.
and that I will notify BWC immediately upon receiving any compensation or benefits from any source for this claim.   (R.C. 2913.48)
Last name, first name, middle initial Social Security number Marital status Date of birth
Single
Home mailing address Sex Married Number of dependents
n Male n Female Divorced
City State 9-digit ZIP code Country if different from USA Separated Department name
Widowed
Wage rate Hour Month Week What days of the week do you usually work? Regular work hours
$ Per: Year Other n Sun n Mon n Tues n Wed n Thur n Fri n Sat From ________ To ________
Have you been offered or do you expect to receive payment or wages for this claim from anyone other than the Ohio Bureau Occupation or job title
Injured worker and injury/disease/death info.

of Workers' Compensation? Yes No If yes, please explain.

Employer name

Mailing address (number and street, city or town, state, ZIP code and county)

Location, if different from mailing address

Was the place of accident or exposure on employer's premises? Yes No

(If no, give accident location, street address, city, state and ZIP code)
Date of injury/disease Time of injury If fatal, give date of death Time employee Date last worked Date returned to work
a.m. p.m. began work a.m. p.m.
Date hired State where hired Date employer notified State where supervised

Description of accident (Describe the sequence of events that directly Type of injury/disease and part(s) of body affected
injured the employee, or caused the disease or death.) (For example: sprain of lower left back)

Benefit application release of information – I am applying for a claim under the Ohio Bureau of Workers’ Compensation Act for work-related injuries that I did not inflict. I affirm that I elect to receive compensation and benefits
under Ohio's 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, the Ohio State Board of Pharmacy, the Ohio Department of Job and
Family Services and the Ohio Rehabilitation Services Commission to release medical, psychological, psychiatric, pharmaceutical, vocational and social information. I understand this may include personally identifying information
that is casually 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, the employer in this claim, the employer’s managed
care organization and any authorized representatives. My previous or future BWC claims may affect decisions made in this claim. Proper administration of the present claim may require BWC to share claims information with the
employers of record (or their authorized representatives) and/or my authorized representative for any and all such previous or future claims. The released claims information may include any record maintained in my claim files.
Injured worker signature Date E-mail address Telephone number Work number
( )
Health-care provider name Telephone number Fax number Initial treatment date
( ) ( )
Street address City State 9-digit ZIP code

Diagnosis(es): Include ICD code(s)

Treatment info.

Will the incident cause the injured worker to

miss eight or more days of work? Yes No Is the injury causally related to the industrial incident? Yes No
E code 11-digit BWC provider number Date

Health-care provider signature

Employer policy number Check Employer is self-insuring

if Injured worker is owner/partner/member of firm
Telephone number Fax number E-mail address Federal ID number Manual number
( ) ( )

Was employee treated in an emergency room? Yes No Was employee hospitalized overnight as an inpatient? Yes No
Employer info.

If treatment was given away from work site, provide the facility name, street address, city, state and ZIP code

Certification - The employer For self-insuring employers only

Rejection - The employer
certifies that the facts in this rejects the validity of this claim for Clarification - The employer clarifies
application are correct and valid. the reason(s) listed below: and allows the claim for the condition(s) below:
Medical only Lost time

Employer signature and title Date OSHA case number

BWC-1101 (Rev. June 12, 2014) This form meets OSHA 301 requirements
FROI-1 (Combines C-1, C-2, C-3, C-6, C-50, OD-1, OD-1-22)
 Physician’s Report of Work Ability

Injured worker name Claim number

Date of injury Date of last appointment/examination Date of this appointment/examination Date of next appointment/examination

MEDCO-14 submission (Select one of the options below.)

I have never completed a MEDCO-14. Proceed to section 2.
1 I have previously completed a MEDCO-14, and all of the information remains the same. Proceed to and complete section 8.
I have previously completed a MEDCO-14, and I am providing updates to each section checked.
Employment/Occupation Complete this section and proceed to section 3 (Updates Yes No )
Have you reviewed the description of the injured worker’s job held on the date of injury (former position of employment)? Yes No
2
If yes - please indicate who (select all sources) provided the job description Injured worker Employer MCO BWC
Work status/Injured worker’s capabilities (Updates Yes No )
Does the injured worker have any work restrictions related to allowed conditions in the claim? Yes No
3A If yes, proceed to section 3B.
If no restrictions, please indicate release to work date ______/______/______. Proceed to and complete sections 6 and 8.
If there are work restrictions, can the injured worker return to his/her job held on the date of injury (former position of
employment)? Yes No
If yes, please indicate release to work date: _____/_____/_____. Proceed to sections 3C, 5, 6, and 8.
3B If no, please indicate when the injured worker initially could not do the job held on the date of injury. Date:_____/_____/_____.
Please estimate when the injured worker should be able to return to the job held on the date of injury for this period of restricted duty.
Date:_____/_____/_____.
Proceed to section 3C.
Please indicate which of the activities listed below the injured worker can perform (even if the response to 3B is “no”.)
The injured worker can perform simple grasping with: Left hand Right hand Both
The injured worker can perform repetitive wrist motion with: Left hand Right hand Both
The injured worker’s dominant hand is: Left Right
The injured worker can perform repetitive actions to operate foot controls or motor vehicles with: Left foot Right foot Both If the
injured worker is taking prescribed medications for the allowed conditions in this claim, is the injured worker able to safely:
*Operate heavy machinery: Yes No *Drive: Yes No *Perform other critical job tasks as defined by any source listed
above in section 2: Yes No
Please indicate the following: N = Never, O = Occasionally, F = Frequently, C = Continuously Lifting/carrying N O F C Pushing/pulling N O F C
Activity N O F C Activity N O F C 0 - 10 lbs. 0 to 25 lbs.
Bend Reach above shoulder 11 - 20 lbs. 26 to 40 lbs.
Squat/kneel Type/keyboard 21 - 40 lbs. 41 to 60 lbs.
Twist/turn Work with cold substances 41 - 60 lbs. 61 to 100 lbs.
Climb Work with hot substances 61 - 100 lbs. 100 + lbs.
3C
In an eight-hour workday, how many total hours is the injured worker able to:
Sit: ____ hours Continuously With break Walk: ____ hours Continuously With break Stand: ____ hours Continuously With break
In the space below please provide any additional information addressing the injured worker’s capabilities and/or job accommodations
which may not be addressed above. _____________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________

BWC-3914 (Rev. June 30, 2015) Proceed to section 4.

MEDCO-14
Injured worker name Claim number Date of injury

Disability period information (If 3B above is NO you must address all fields, including site/location if applicable) (Updates Yes No )
Complete the chart below and furnish the narrative description of the diagnosis(es), site/location, if applicable, and International
Classification of Diseases (ICD) code(s) for the condition(s) being treated due to the work-related injury/disease. Please indicate if
the condition is preventing the injured worker from returning to job duties he/she held on the date of injury.
Site/location ICD Is the condition preventing full duty release to the
Narrative description of the work-related allowed condition
if applicable code job injured worker held on the date of injury?

Yes No
4A
Yes No

Yes No

Yes No

Yes No
List all other relevant conditions that impact treatment of the conditions listed above (e.g., co-morbidities or not yet allowed conditions).
4B

Clinical findings: Office notes can be referenced in lieu of writing clinical findings below. (Updates Yes No )
The injured worker is progressing: As expected Better than expected Slower than expected
Provide your clinical and objective findings supporting your medical opinion outlined on this form. List barriers to return to work and
reason, for the injured worker’s delay in recovery.

Maximum medical improvement (MMI) (Updates Yes No )

MMI is a treatment plateau (static or well-stabilized) at which no fundamental functional or physiological change can be expected within
reasonable medical probability, in spite of continuing medical or rehabilitative procedures. Has the work-related injury(s) or occupational
disease reached MMI based on the definition above? Yes No
If yes, give MMI date: ______/______/______. If no, please provide the proposed treatment plan, including estimated duration of each
6 treatment (attach additional sheet if necessary).

Note: An injured worker may need supportive treatment to maintain his or her level of function after reaching MMI. Thus, periodic medical treatment
may still be requested and provided.
Vocational rehabilitation (Updates Yes No )
Vocational rehabilitation is an individualized and voluntary program for an eligible injured worker who needs assistance in safely returning to
work or in retaining employment. This program can be tailored around an injured worker’s restrictions and may provide job seeking skills or
necessary retraining. Is the injured worker a candidate for vocational rehabilitation services focusing on return to work?
7 Yes No If no, please explain why and provide your recommendations to help the injured worker return to employment.

Treating physician signature - mandatory

I certify the information on this form 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 be punished, under appropriate
criminal provisions, by a fine or imprisonment or both.
Treating physician’s name (please print legibly) Address, city, state, nine-digit ZIP code, telephone and fax numbers
8
Treating physician’s signature

BWC provider (Peach) number Date

BWC-3914 (Rev. June 30, 2015)

MEDCO-14
Workers' compensa�on iden�fica�on card

24-hour customer service: 888.627.7586

Employer name: Type employer name here

Policy number: Type policy number here
Please provide MEDCO-14 form with any physical restric�ons, as employer
may have modified duty available.

Please send all informa�on within 24 hours of visit.

Injury report and FROI fax: 888.711.9284
Medical and authoriza�on fax: 888.627.0074
Customer service: 888.627.7586
Prescrip�on ques�ons: 800.644.6292 (follow prompts)

Send all mail and medical bills to:

Sedgwick Managed Care Ohio
PO Box 1040 This card is not a
Dublin, OH 43017 guarantee of coverage.