Employer's First Report of Injury or Illness (DWC-1S)
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Online entry of the DWC-1S is mandatory
March 24, 2004 (pdf)
Required:
Form DWC-1S must be completed and submitted to SORM for any on-the-job
injury that:
- Has more than one day of lost time;
- Is an occupational disease, with or without lost time or medical
expenditures;
- Resulted in the death of the employee; or
- Results in expenditures for medical treatment or service.
It is important that every box be completed on the DWC-1S form.
Incomplete or missing data often prevents efficient processing of
the DWC-1S and can prevent injured employees from receiving benefits
in a timely manner. If a box is not applicable, fill it in with
N/A.
PLEASE NOTE: If an on-the-job injury is not an
occupational disease, does not result in medical treatment, does
not result in the death of the employee or results in less than
one day of lost time, the employer will keep the record on file
only.
Filing Deadline:
The form must be received by SORM not later than the 5th calendar
day after the first notice of injury is reported to the employing
agency.
PLEASE NOTE: When an employee suffers a severe
or fatal injury, please contact SORM by phone and fax the form immediately.
Keep the original in your file.
Completed by:
The claims coordinator.
Instructions:
PLEASE COMPLETE ALL APPLICABLE FIELDS. Most fields are self-explanatory;
however, the following items may require more attention:
Item 4: If no home phone, please give a phone number where the employee
can be reached.
Item 7: Employees work phone number.
Item 8: This information is no longer required.
Item 13: This information should include the doctor's telephone
number.
Item 15: This should be the actual date of injury, or (for occupational
diseases) the date the employee knew or should have known the condition
was work-related.
Item 17: This should be the first full day of lost-time from work.
(Please note that the date of injury is not considered the first
day of lost time.) Mark NLT or N/A if there is no lost time.
Item 18: List the nature of the injury. Examples include: burn,
cut, or sprain.
Item 19: List specific body part, which side of body is affected,
e.g., chin, right leg, left upper arm, etc. If more
than one body part is affected, list each part.
Item 20: Describe in detail. Use additional sheet of paper if necessary.
Item 24: This should state the specific substance or exposure that
directly inflicted the injury such as a tool, chemical (list the
name of the chemical), or machine.
Item 26: The date should be entered even if the employee has returned
to work even for a portion of the day. If the employee has returned
to work making less than his or her pre-injury wage, a DWC-6 must
also be submitted.
Item 28: This is the employee's immediate supervisor. Please include
a work telephone number.
Item 29: This is the date the employee reported the injury to the
employer as work related.
Item 34: This 4-digit code corresponds to the primary occupation
in which the employee was engaged at the time of the injury or exposure.
This code is from the state payroll classification table and is
available from the State Comptroller of Public Accounts.
Item 43: This 9-digit code represents the location of the agency
unit that employed the injured worker at the time of their injury
or exposure. The first three digits will be 100 for state agencies
or 200 for county entities. The second three digits are the agency
code. The third three digits are the location code as established
by each agency. Contact the SORM's Risk Assessment and Loss Prevention
section for information about or changes to your agency location
code(s).
Item 44: This 9-digit code is assigned to each agency by the Internal
Revenue Service for employment, tax, and reporting purposes.
Item 45: This 2-digit code is assigned to each agency according
to its primary business activity. For specific questions regarding
your NAICS code, call your local Texas Workforce Commission (TWC).
Item 46: This is a 3- or 4-digit code for the specific subsector
of the business activity of the agency.
Item 47: This is the state agency code number assigned by the State
Comptroller of Public Accounts.
Item 51: This must be the signature and title of the claims coordinator.
If signed by someone other than the claims coordinator, he or she
must list his or her title and state that it was signed for the
claims coordinator. The date must also be included.
Item 52: Enter the number of sick/annual leave hours credited to
the employee as of the date of injury.
Distribution:
Fax a copy or mail the original to:
State Office of Risk Management
Mail a copy to the claimant.
Retain a copy for your file.
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Agency Violations |
Employers have important responsibilities under the Workers' Compensation
Act. Along with health care providers, they are a primary source
of information for the carrier to use to administer claims. Without
the employers' and health care providers' assistance, carriers are
hard pressed to timely and appropriately deliver benefits to injured
employees. Failure to provide complete, timely information will
result in penalties that can be quite substantial. A state agency
is the employer and has a duty under the Texas Department of Insurance, Division of Workers' Compensation
Act to timely and accurately provide information to the State Office
of Risk Management (insurance carrier) so that injured employees
can receive the benefits they are entitled to. Although many employees
use accumulated leave as a form of salary continuation for injuries,
this does not remove the employers' responsibilities with regard
to reporting.
DWC-1, Employer's First Report of Injury Texas Labor Code §409.005
and DWC Rule 120.2
The Employers' First Report of Injury must be filed within 8 days
of the date the employer received notice of the injury or an occupational
disease or the 8th day after the employee's absence for more than
one day from work due to the injury or death.
Failure to timely report the lost time in this manner may be subject
to a penalty not to exceed $500 unless it is part of a pattern of
practice which is subject to a penalty not to exceed $10,000.
Do not send this form to the DWC, unless the Commission specifically
requests a direct filing.
If a report has not been received by the carrier, SORM, the employer
has the burden of proving that the report was filed within the required
time frame.
This report may not be considered admission or evidence against
the employer or the insurance carrier in any proceeding before the
Commission or a court in which facts set out in the report are contradicted
by the employer or insurance carrier. |
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