Forms & Publications for the Employer Reporting Pilot Project

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Print project letters, forms, & publications

Print these documents yourself unless it's marked as order only.

Note: These documents are intended to be used exclusively by participating employers. They are listed on this page only and are not included in L&I's forms and publications database.

Letters

Letters
Date	Title/Description
Jun 26, 2009	Employer Update Letter (June 2009) (23 KB PDF).
Oct 8, 2008	Employer Update Letter (October 2008) (23 KB PDF).
Feb 26, 2008	Employer Update Letter (February 2008) (23 KB PDF).
Dec 1, 2007	Employer Assisted Injury Reporting - Report to the Legislature (49 KB PDF).
Mar 22, 2007	Employer Update Letter (March 2007) (27 KB PDF).
Feb 16, 2007	Employer Update Letter (February 2007) (24 KB PDF).
Feb 16, 2007	Health Care Provider Letter (February 2007) (33 KB PDF).
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Forms

Forms
Number	Title/Description
F242-381-000	Industrial Injury or Occupational Disease Reporting Log (144 KB PDF) This form may be printed on 8 1/2 x 11 or 8 1/2 x 14 sheets.
F242-390-000	Employers Report of Accident (ROA) — order only. This form is not the same as the one used by providers. Order this form.
F242-390-999	Instrucciones para el Reporte de Lesión Industrial o Enfermedad Ocupacional del Empleador Departamento de Labor e Industrias (Instructions in Spanish for completing the F242‑390‑000 Employer's Report of Industrial Injury or Occupational Disease) (228 KB PDF).
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Publications

Publications
Number	Title/Description
F242-375-909	Worker Checklist (174 KB PDF) This checklist is for workers in companies that are participating in the Employer Reporting Pilot Project. It explains what a worker should do if a workplace injury/disease occurs.
F242-376-000	Employer Checklist (133 KB PDF) This checklist is for employers that are participating in the Employer Reporting Pilot Project. It explains what an employer should do if a workplace injury/disease occurs.
F242-377-000	Questions and Answers for Workers (137 KB PDF) Explains the Employer Reporting Pilot Project and how it works. Lets workers in companies that are participating in the project know they have a choice of filing a worker's compensation claim through their employer or health-care provider and how to do it.
F242-377-999	Questions and Answers for Workers (Spanish) (183 KB PDF) See explanation above.
F242-378-000	Questions and Answers for Employers (156 KB PDF) Explains the Employer Reporting Pilot Project and how it works. Answer specific questions employers participating in the project may have about the project and their responsibilities.
F242-379-909	Poster - Employer Reporting Pilot Project (94 KB PDF) Companies participating in the Employer Reporting Pilot Project must display this poster where their workers can see it. The poster lets workers in these companies know they have the choice of filing a workers' compensation claim with their employer or their health-care provider. This poster should be printed on 11 x 17 sheets.
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