LS-202 Employer's First Report of Injury or Occupational Illnes

U.S. Department of Labor

Employer's First Report of Injury
or Occupational Illness

Office of Workers' Compensation Programs

(See instructions on reverse)

Print

OMB No. 1240-0003

Reset

1. OWCP No.

2. Carrier's No.

3. Date and Time of Accident
(mm/dd/yyyy)

5. Employee's address (No., street, city, state, ZIP, country)

4. Name of injured/deceased employee (Type or print - first, M.I., last)
M.I.

First Name

Last Name

Telephone

Street:
City:

6. Injury is reported under the following
Act (Mark one)

7. Indicate where injury occurred
(Longshore Act only) (Mark one)

A

Longshore and Harbor Workers'
Compensation Act

A

B

Nonappropriated Fund Instrumentalities Act

Aboard vessel or over
navigable waters

B

Pier/Wharf

C

Outer Continental Shelf Lands
Act

C

Dry dock

D

Defense Base Act

D

Marine terminal

E

Building way

F

Marine railway

G

Other adjoining area

1. Contracting Agency
2. Prime Contract #
3. Sub-Contract #

10a. Nationality (DBA only)

11. Did injury cause death?
No
Yes - If yes, skip to 16
12. Did injury cause loss of time beyond
day or shift of accident?
13. Date and hour employee
first lost time
because of injury

No
21. Which days usually worked per week?
S
M
T
W
(Mark (X) days)

T

Date

(mm/dd/yyyy)

Yes
No
Time

(hh:mm am/pm)

16. Was employee doing usual work when
injured/killed? (if no, explain in Item 26)

F

Yes
No

19. Occupation

S

24. Exact place where accident occurred (See instructions
on reverse). This item should specify area if accident
was in maritime employment and occurred in area
adjoining navigable waters.

a. Hourly

(mm/dd/yyyy)

by law)

Yes 18. Dept. in which employee normally works(ed)

23. Wages or earnings (include
overtime, allowances, etc.)

Ctry:

F

10. Social security no. (Required

17. Did injury/death occur on
employer's premises?
(hh:mm am/pm)

Zip:

9. Date of birth
M

Yes 15. Date & hour empl returned to work
(mm/dd/yyyy) (hh:mm am/pm)
No

(mm/dd/yyyy)

St:

8. Sex

14. Did employee stop work
immediately?

20. Date and hour pay stopped

(hh:mm am/pm)

22. Date employer or foreman first knew of accident.
(mm/dd/yyyy)

(hh:mm am/pm)

25. How was knowledge of accident or
occupational illness gained?

b. Daily
c. Weekly
d. Yearly
26. Describe in full how the accident occurred (Relate the events which resulted in the injury or occupational disease. Tell what the
injured was doing at the time of the accident. Tell what happened and how it happened. Name any objects or substances involved and tell
how they were involved. Give full details on all factors which led or contributed to the accident.)

27. Nature of Injury (Name part of body affected - fractured left leg, bruised right thumb, etc.) If there was amputation of a member of the body, describe.

28a. Has medical attention
been authorized?

Yes
No

28b. LS-1 issued?
Yes

No

Name of:

29. Enter date of
authorization.

30. Was first treating
physician chosen
by employee?

Yes
No

31. Has insurance
carrier been
notified?

Yes
No

Address - Enter number, street, city, state, zip code

32. Physician
33. Hospital
34. Insurance
Carrier
35. Employer
36. Employer's
Business
38. Official title and phone number of person signing this report

37. Signature of person authorized to sign for employer
Name of person signing this report

Phone number

39. Date of this report
(mm/dd/yyyy)
Form LS-202
Rev. April 2012

This report is to be filed in duplicate with the District Director in the appropriate district office of the Office of Workers’ Compensation
Programs and is required by 33 U.S.C. 930(a). File form within 10 days from the date of injury or death or from the date the employer
first has knowledge of an injury or death. Under the law all medical treatment and compensation must be furnished by the employer or
its insurance company. Treatment must be by a physician chosen by the employee, unless the physician is on a list of physicians
currently not authorized by the Department of Labor to render medical care under the Act. Compensation payments become due and
are payable on the 14th day after the employer first has knowledge of the injury or death. Penalties may be charged for failure to comply
with provisions of the law. The information will be used to determine entitlement to benefits. Persons are not required to respond to
this collection of information unless it displays a currently valid OMB control number.

REPORTABLE INJURY – Any accidental injury which causes loss of one or more shifts of work or death allegedly arising out of and
in the course of employment, including any occupational disease or infection believed or alleged to have arisen naturally out of
such employment, or as a natural or unavoidable result from an accidental injury. If the employer controverts the right to
compensation it must also file a notice of controversion with the District Director within 14 days after it has knowledge of the
alleged injury or death.
Item 6 – A. Longshore and Harbor Workers’ Compensation Act
covers employees injured while engaged in maritime
employment upon the navigable waters of the United States
(including any adjoining pier, wharf, dry dock, terminal,
building way, marine railway, or other adjoining area
customarily used by an employer in loading, unloading,
repairing, or building a vessel); - employees injured upon the
navigable waters of the United States and other described
areas who at the time of injury were engaged in maritime
employment and are not otherwise specifically excluded under
the Act (33 U.S.C. 902).

Item 24 – “Exact place where accident occurred” requires the
nearest street address, city and town. In addition l

If on a vessel,
Give place on vessel where injury happened (Deck, hold,
tweendeck, engine room, etc.) Name of vessel

l

If either on an adjoining pier, wharf, dry dock, terminal
building way, marine railway, or other area customarily
used in loading, unloading, repairing, or building a
vessel

B.
Nonappropriated Fund Instrumentalities Act covers
employees of nonappropriated fund instrumentalities of the
Armed forces, e.g., post exchanges, motion picture service,
etc.
C. Outer Continental Shelf Lands Act covers employees of
private employers engaged in operations conducted on the
Outer Continental Shelf for the purpose of exploring for,
developing, removing, or transporting by pipeline the natural
resources of submerged lands.

Name or number of pier, dry dock, marine railway, etc.
Name of the terminal or shipyard
Nearest street address – City and State
l

If injury or death is reported under the Defense Base
Act, give the name of the country where injury or death
occured.

l

If on the Outer Continental Shelf,

D. Defense Base Act covers any employment (1) at military,
air, and naval bases acquired by the United States from foreign
countries; (2) on lands occupied or used by the United States
for military or naval purposes outside the continental limits of
the United States; (3) upon any public work in any Territory or
possession outside the continental United States under a
contract of a contractor with the United States; (4) under a
contract entered into with the United States where such
contract is to be performed outside the continental United
States and at places not within the areas described in (1), (2),
and (3) above for the purpose of engaging in public work; (5)
under certain contracts approved and financed by the United
States under the Mutual Security Act of 1954, as amended; and
(6) in the service of American employers providing welfare or
similar services for the benefit of the Armed Forces outside the
Continental United States.

Give drilling site and block number
Area name (e.g. West Delta Area)
Federal Lease Number, State Lease Number
Distance from and name of nearest land,
name of State

NOTE: FILING THIS FORM DOES NOT CONSTITUTE AN ADMISSION OF LIABILITY UNDER THE COMPENSATION ACT. Any
employer, insurance carrier, or self-insured employer who knowingly and willfully fails to submit this report when
required or knowingly or willfully makes a false statement or misrepresentation in this report shall be subject to a civil
penalty not to exceed $11,000 for each such failure, refusal, false statement, or misrepresentation. [33 U.S.C.930(e)] This
report shall not be evidence of any fact stated herein in any proceeding in respect to any such injury or death on
account of which the report is made. [33 U.S.C. 930(c)]
Public Burden Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection
displays a valid OMB control number. Public reporting burden for this collection of information is estimated to average 15 minutes per response,
including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and
reviewing the collection of information. Use of this is optional, however furnishing the information is required in order to obtain and/or retain
benefits (33 U.S.C. 930(b)). Send comments regarding the burden estimate or any other aspect of this collection of information, including
suggestions for reducing this burden, to the U. S. Department of Labor, 200 Constitution Avenue, N.W., Room C-4319, Washington, D.C. 20210,
and reference the OMB Control Number. DO NOT SEND THE COMPLETED FORM TO THIS OFFICE