University of Oregon Environmental Health & Safety

(Form 801 is Available at the Bottom of This Page)

No Medical Treatment:

If the employee does not seek medical treatment, the supervisor, with the employee’s assistance, will complete the Supervisor’s Accident Investigation Report (SAIR). Send the SAIR to Environmental Health & Safety (EHS) within 24 hrs. Do not complete the Workers’ Compensation Claim Form (801) unless the employee later seeks medical treatment.

Medical Treatment:

If the employee seeks medical treatment, the supervisor and employee will complete the SAIR and 801. Instructions below.
Notify EHS at 346-3192, 346-2958 or 346-5421 immediately, if the employee is admitted to the hospital as an inpatient or dies as a result of the injury or illness.

IMPORTANT: THE SAIR AND 801 MUST BE FORWARDED TO THE CLAIMS COORDINATOR AT EHS WITHIN 24 HOURS OF THE EMPLOYEE’S NOTIFICATION OF A JOB INJURY OR ILLNESS. FORMS CAN BE FAXED TO 346-7008.

Employee is Not Available to Complete the Worker Section of the 801

If the employee is temporarily incapacitated or not available to fill out the 801, complete the known information on the Worker (top) section of the 801. Leave unknown information blank. Complete the SAIR.
Complete the Employer (bottom) section of the 801. Instructions below. Fax or mail the 801 and SAIR to EHS within 24 hours. The employee must finish and sign the forms as soon as he/she is available. Send the completed originals to EHS.

Questions???

Contact the Claims Coordinator, Environmental Health & Safety (EHS), at 346-2958 or michgill@uoregon.edu.
Forms can be faxed to 346-7008.

Instructions for EMPLOYER Section of the 801

29.	University of Oregon
30	(541) 346-2958
31.	93-6001786
32.	Does not apply. Leave blank.
33.	Does not apply. Leave blank.
34.	1230 Franklin Blvd., Eugene, OR 97403-5224
35.	419502S
36.	Write the name and address of the office or building location to which the employee is assigned. For example, Human Resources, 1585 E 13th Ave, Rm 463, Eugene, OR 97403-5210.
37.	Education
38.	Write the address where the actual injury took place. This may be an office, building, intersection, mile marker or geographical location other than the location at which employee usually works.
39.	Mark the yes or no box. If you are uncertain, leave both boxes blank. If the answer is yes, contact the Claims Coordinator. The machine or product may need to be preserved for inspection.
40.	9499
41.	Mark the yes or no box. If you are uncertain, leave both boxes blank.
42.	Mark the yes, no or unknown box. Answer “yes” if you have first hand knowledge that the injury was caused by work. If it is not apparent that the injury or illness occurred while the employee was performing his/her duties, check “unknown”. Check “no”, if you are certain the injury or illness did not occur during the course and scope of employment.
43.	Leave blank.
44.	Write the exact date a manager or supervisor first knew that medical treatment was required for the injury or illness. It may be the date of injury or later date, if the employee does not seek immediate medical treatment.
45.	Write the monthly salary or hourly wage, if known. If you do not have this information, leave blank.
46.	Write the employee’s date of hire. If the employee terminated employment and was later rehired, put the new date of hire. Leave blank, if the date of hire is unknown or not clear.
47.	Report a fatality immediately to EHS at 346-3192, 346-2958 or 346-5421 AND the Department of Public Safety at 346-6666.
48.	Mark the appropriate box for return to work and provide a date when the status occurred. The “modified” work status means the employee returned to work with written restrictions or limitations as determined by a physician. Notify the Claims Coordinator at EHS immediately of any time loss from work (other than for medical appointments). Also, keep the Claims Coordinator apprised of any changes in work status.
49	Mark either yes or no. If you are uncertain, leave blank.
50.	To be signed by the person completing the form (supervisor/manager or other designated person).

Contact:
Michelle Gillette
Campus Claims Manager
Phone: (541) 346-2958
E-Mail: michgill@uoregon.edu