OWCP LS-202 Incident Form

Last Report Generated (click to view or download)
 Employer Name
 Location Where Employed
 Department Where Employed
 Hidden Record ?
 Record Marked for Delete ?

        Basic Case Information
 Report Number
 Date Of Injury
 For Information Only
 Claim Status
 OWCP Number
 Carrier Number
 Social Security Number  -   - 
 Employee First Name
 Employee Middle Initial
 Employee Last Name

        Employee Information
 Update from Employee Data Table    (to update save record)

 Employee Address
 Employee City
 Employee County
 Employee State
 Employee Country
 Employee Postal Code  - 
 Employee Phone  )   - 
 Employee Date Of Birth
 User Defined EmployeeID
 Occupation Description
 Date Hired
Which Days Usually Worked per Week
Mon Tue Wed Thur Fri Sat Sun
 Wage Hourly
 Wage Daily
 Wage Weekly
 Wage Yearly

        Incident Description
Type Of Injury
If Injury involves Amputation, Describe (75 characters max)
Part Of Body Injured
Side Of Body Injured
Cause Of Injury
Location Of Injury
 Occur on Employer Premises ?
 Where Event Occurred (OSHA)
Where Event Occurred Details required by item 24 of LS 202 instructions (100 characters max)
 Postal Code  - 
Activity engaged in when injury occurred (150 characters max)
Object or Substance That Directly Injured Employee
(150 characters max)
How Injury Occurred (150 characters max)
 Time Employee Began Work
 Time Of Injury
 Reported Under Act
 If Reported Under DBA, Contracting Agency
 If Reported Under DBA, Contract Number
 Where Injury Occurred LS Act
 Stop Work Immediately?
 Lost Time Beyond Shift
 Date Lost Time Began
 Time Lost Time Began
 Date Pay Stopped
 Time Pay Stopped
 Date Employer Notified
 Time Employer Notified
 Date Returned To Work
 Time Returned To Work
 Doing Usual Work When Injured?
 If fatal, give date of death
How Was Knowledge of Injury Gained (75 characters max)

        Medical Treatment
 Has Medical Care Been Authorized?
 Has LS-1 Been Issued?
 Date Medical Authorized
 Did Employee Choose Physician?
 Treated In Emergency Room
 Hospitalized Overnight
 Physician Name
 Physician Address
 Physician City
 Physician State
 Physician Postal Code  - 
 Physician Phone  )   - 
 Hospital Name
 Hospital Address
 Hospital City
 Hospital State
 Hospital Postal Code  - 
 Hospital Phone  )   - 

        OSHA Recordability
 Auto Calculate Days Away or
 Restricted Time Days
 Number of Days Away
 Number of Restricted Work Days
 Use Privacy Case Test
 Privacy Case
 Use OSHA Recordability Test
 OSHA Recordable

        Employer/Preparer/Misc Information
 Date Prepared
 Preparer's Name
 Preparer's Title
 Preparer's Phone  )   - 
 Has Carrier Been Notified?

        Identification Code
 Code Description
 Code Value

        User Defined Fields
 User Defined Text 1
 Total Med Cost in $
User Description (100 characters max)
 User Defined Date 1
 User Defined Date 2
User Defined Comment (300 characters max)

        Report History
Report History (click to view or download)

 Release Status
 Release Date
 Release Actions
Release Comments (300 characters max)