Form 801 English — Report of Job Injury or Illness

Form 801 Spanish — Reporte de Lesión o Enfermedad en el Trabajo (801s) 

Form 2223a English — Worker Request for Reconsideration

Form 2223 a Spanish — Petición del Trabajador para Reconsideración


The Ombudsman for Injured Workers is transferring to a new phone system on Aug. 23. If you are having trouble reaching the office by phone, email

Contact us:

800-927-1271 (toll-free)​​