Forms
Forms
Please Note: The use of these forms requires the user to have installed Adobe Reader, version 8.0 or later. It is recommended that the user obtain (or upgrade to) the latest available Reader version offered by Adobe Systems, Inc., the creator. To download Adobe Reader directly from the Internet, simply click on the link below.If necessary, please download Adobe Reader.
Static forms need to be printed and completed manually.
Interactive forms may be opened online or downloaded to your PC and completed at a later time when offline. Interactive forms enable the user to enter information directly into the forms. Forms which require a signature or other type of manual authentication need to be printed, signed or authenticated, then transmitted to this office.
| Form Number | Form Name | Last Updated |
|---|---|---|
| ADOSH_2212 | Report a Fatality or Severe Injury Form | 03/20/23 |
| ADOSH_2213 | Notice of Alleged Safety or Health Hazards Form | 03/20/23 |
| ADOSH_2215 | Discrimination / Whistleblower Complaint Form | 03/20/23 |
| ADOSH_2217 | Consultation Request Form | 03/20/23 |
| ADOSH_2218 | ADOSH Training Request Form | 03/20/23 |
| ADOSH_2221 | Application for Permit to Install or Alter Elevator Form | 03/20/23 |
| ADOSH_2222 | Request for Boiler Repair Form | 03/20/23 |
| ADOSH_2223 | Request for Boiler Certificate Form | 03/20/23 |
| ADOSH_2224 | Compliance Assistance Request Form | 06/30/21 |
| ADOSH_2225 | VPP Pre-Screening Form | 06/25/21 |
| ADOSH_2226 | SHARP Application Form | 06/13/22 |
| ADOSH_2227 | Elevator Inspection (PEI) New Application | 03/20/23 |
| ADOSH_2232 | Boiler Inspector (PBI) Renewal Application | 03/20/23 |
| Form Number | Form Name | Last Updated |
|---|---|---|
| ALJ_8801 | Interested Party Workers’ Compensation Document Submission | 03/07/18 |
| Form Number | Form Name | Last Updated |
|---|---|---|
| Claims_0101 | Employer Report of Injury Form | 06/07/19 |
| Claims_0102 | Worker’s and Physician’s Report of Injury Form | 12/06/19 |
| Claims_0113 | Employee Rejection of Terms Form | 08/12/16 |
| Claims_0114 | Employee Revocation of Rejection of Terms Form | 08/23/16 |
| Claims_0120 | Dependent Benefits Claim Form | 06/07/19 |
| Claims_0121 | Request to Change Doctors Form | 06/07/19 |
| Claims_0122 | Request to Leave State Form | 06/07/19 |
| Claims_0123 | Professional Employer Agreement Form | 09/16/16 |
| Claims_0124 | Bodily Fluids Work Exposure Form | 09/16/16 |
| Claims_0407 | Worker’s Report of Injury Form | 03/23/22 |
| Claims_0446 | Request for Hearing Form | 06/07/19 |
| Claims_0528 | Petition to Reopen Form | 06/07/19 |
| Claims_0529 | Petition for Rearrangement Form | 06/07/19 |
| Claims_110A | Annual Report of Income Form | 08/12/16 |
| Claims_110B | Notice of Intent to Suspend Form | 08/12/16 |
| Form Number | Form Name | Last Updated |
|---|---|---|
| Labor_3303 | Unpaid Wage Claim Form | 02/25/22 |
| Labor_3304 | Payment Compliance Complaint Form | 02/25/22 |
| Labor_3305 | Earned Paid Sick Time Claim Form | 02/25/22 |
| Labor_3306 | Youth Labor Complaint Form | 02/25/22 |
| Labor_3307 | EPST/Minimum Wage Retaliation Claim Form | 02/25/22 |
| Labor_3325 | Minimum Wage Claim Form | 02/25/22 |
| Form Number | Form Name | Last Updated |
|---|---|---|
| Legal_4401 | Public Records Request Form | 04/01/20 |
| Legal_4402 | Uninsured Employer Complaint Form | 09/03/20 |
| Legal_4403 | Employers Workers Compensation Insurance Inquiry Response Form | 07/12/17 |
| Legal_4404 | Petition for Attorney’s Fees | 03/08/18 |
| Form Number | Form Name | Last Updated |
|---|---|---|
| MRO_7711 | Medical Treatment Preauthorization Form | 09/27/18 |
| Form Number | Form Name | Last Updated |
|---|---|---|
| SpecFund_5413 | Workers Supplemental Claim Form 413 | 08/12/16 |
| SpecFund_5525 | Carrier's Notification of Scheduled Injury Time Loss | 08/12/16 |
| SpecFund_5526 | Workers Supplemental Claim For Compensation | 01/18/17 |
| SpecFund_5527 | Apportionment Settlement Letter | 02/01/21 |
| SpecFund_5528 | Vocational Rehabilitation Referral | 06/07/19 |
