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Welcome to the Oregon Workers' Compensation Division's Form 801 video. This video was created 
by the Oregon Department of Consumer and Business Servicesā€™ Ombuds Office for Oregon Workers. We created  
this video to help guide you through how to complete the worker portion of Form 801, Report 
of Job Injury or Illness. To make a claim for a work-related injury or illness, you will need to 
fill out the worker portion of Form 801 and give it to your employer. If you do not intend to file 
a workers' compensation claim with the insurance  company, do not sign the signature line. After you fill out and hand in the form, your employer should give you a copy of the form for your records. The

first step is to fill in the date your injury or  illness occurred. This gets a little trickier to do 
in cases of injuries or illnesses that happen over
time with no clear start date. In those cases, time with no clear start date.

you may want to use the date of your diagnosis or the last date you worked if you are no longer employed 

by the employer at injury. Next, you will want to fill in the date you left work due to the injury or illness. In many cases, this is the same as the date of injury. However, if you did not miss time from work, you should leave this section blank.  You 
will then fill in the time you began work on the date of your injury. This is the time you started your shift. In the next box, you will indicate your  
regularly scheduled days off. If you have days off  that change week to week, don't check any boxes or  write "varied." Ignore this next section. It is only used by the Workers' Compensation Division. You will  next fill in the time your injury or illness occurred. Leave this section blank in cases of

occupational disease or if you are unsure of  the time the injury or illness happened. Next, you will fill in the time you left work on the date of injury. Again, leave this section blank 
in cases of occupational disease or if you are unsure of the time the injury or illness happened. In the next box, you will want to make a check mark if you have more than one job. This box is very important and a way to notify the insurer or service company that there may be supplemental 
disability (in other words, lost wages for a job or jobs other than the job at injury). Next, you

will answer the question, "What is your illness or injury?"¯ Make sure your answer includes the body 
part and that you check the box indicating which side of the body is the injury. For example, if your 
injury is a sprained right foot, you would write "sprained right foot"¯ in the space provided below and check the box indicating the right side of  the body. Next, you will explain what caused your 
injury or illness, and what you were doing at the time. Make sure you include any tools, equipment, vehicles, machinery, etc. that were involved in the injury. A perfect example of the level of detail

needed is provided on the form: The worker fell 10 feet when climbing an extension ladder 
while carrying a 40-pound box of roofing materials. This next section is where you put your personal 
information, such as your legal name, language preference, birthdate, gender, mailing address, home phone, work phone, and occupation. In the next box, list any names of witnesses to your injury or illness, if any. If you have health insurance, you will provide the name and number of the insurance company in this box. Leave this area blank if 
you do not have health insurance. In the next

box, provide the name and address of the hospital or clinic you were treated at for your injury or  illness. Leave this area blank if you have not yet sought medical treatment. You will then answer the

next two questions "Were you hospitalized overnight? Were you treated in the emergency room?" by checking the appropriate boxes, yes or no. Please read this next section carefully before signing the form. The section says: By my signature, I am making a claim for workers' compensation benefits. The

above information is true to the best of my knowledge and belief. I authorize health care providers and other custodians of claim records to release relevant medical records to the workers' compensation insurer, self-insured employer, claim administrator, and the Oregon Department of Consumer and Business Services. Notice: Relevant medical records include records of prior treatment for the same conditions or of the injuries to the same area of the body. A HIPAA authorization is not required. Release of HIV/AIDS records, certain drug and alcohol treatment records, and 
other records protected by state and federal law requires separate authorization. I understand I have

the right to see a health care provider of my choice, subject to certain restrictions under Oregon Revised Statute 656.260 and Oregon Revised Statute 656.325. Once you have read the above statement, it is time to sign, print, and date the form. Once 
you have completed the worker portion of Form 801, return it to your employer. The employer will then fill out the employer portion of the form and will have up to five days to report the claim. If your employer is no longer in business, you are no longer employed with them, or the employer refuses to file the claim, please contact the Ombuds Office for Oregon Workers. We can help you get your claim filed. Call toll-free 800-927-1271 or email oow.questions@dcbs.oregon.gov.

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