Forms & Reporting Procedures

 

• Accident-Report-Form (ARFIE).pdf(PDF, 664KB)
• List-of-Providers.pdf(PDF, 332KB)
• Medical-Release-Form.pdf(PDF, 102KB)
• First-Report-of-Injury-FROI.pdf(PDF, 889KB)
• MEDCO-14 Physician's Report of Workability.pdf(PDF, 443KB) 
  For your provider of record to complete after every office visit involving a workers' compensation claim.
• C-84.pdf(PDF, 188KB) 
  A request for temporary disability benefits while you are off work and recuperating.
• Prescription-Card.pdf(PDF, 234KB)
• C-86.pdf(PDF, 56KB) 
  A C-86 Motion is a request for (action) on your claim.
  
  
  

  Reporting an Injury

  In the event you are injured on the job, the Employee Accident Report Form (ARFIE)(PDF, 664KB) must be completed for all work-related injuries or illnesses within 24 hours of the incident.  See the above forms to download the ARFIE. 

  If you seek medical treatment for this injury, you are required to complete the BWC First Report of Injury  -  (FROI) and a Medical Information Release (see the above forms).
  
  Employee Responsibilities:

  1. Seek medical treatment if necessary. Review the list of Certified Medical Providers(PDF, 332KB) if needed (see list of providers above).
  2. Notify your supervisor or designated person in charge.
  3. Fully complete pages 3 and 4 of the employee information and accident information sections of the ARFIE. Sign and date the employee section of the ARFIE.
     • If you seek treatment, complete the following forms:
       • First Report of Injury (FROI)(PDF, 889KB)
       • Medical Release Form(PDF, 102KB)
       • Physicians’ Report of Work Ability (MEDCO-14)(PDF, 443KB)
         If you have missed work as a result of your injury, or need light duty restrictions, your provider must complete a Medco-14 in order for you to return to work. When you attend your initial appointment, have your doctor complete this form and fax directly to Risk Management (614) 525 - 5715 or email to risk@franklincountyohio.gov.
     • If treatment is sought and a prescription is needed, see the Pharmacy Card and additional information above (Prescription Card(PDF, 234KB)).
  4. Give the ARFIE to your supervisor to complete page 5 and sign the supervisor section of the incident report.

  Supervisor / Manager Responsibilities:

  1. If the employee needs or desires medical treatment, assist in the arrangement of appropriate care.
  2. Review and complete the supervisor section of the ARFIE report and sign as indicated on page 5.
  3. Make a copy of the report for your records and provide the original to the employee.
  4. In case of a severe injury that incapacitates an employee, complete as much information on the ARFIE as possible and submit the report to Risk Management immediately.  Risk@franklincountyohio.gov.  Or call Kimberly Kimmel Risk Manager at (614) 545-4642.