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Form Number Form Name Last Updated
ADOSH_2212 Report a Fatality or Severe Injury Form 09/08/2023
ADOSH_2213 Notice of Alleged Safety or Health Hazards Form 09/08/2023
ADOSH_2215 Discrimination / Whistleblower Complaint Form 09/08/2023
ADOSH_2217 Consultation Request Form 09/08/2023
ADOSH_2218 ADOSH Training Request Form 09/08/2023
ADOSH_2221 Application for Permit to Install or Alter Elevator Form 09/08/2023
ADOSH_2222 Request for Boiler Repair Form 08/12/2016
ADOSH_2223 Boiler New Install-Reinstall form 05/09/2024
ADOSH_2224 Compliance Assistance Request Form 09/21/2023
ADOSH_2225 VPP Pre-Screening Form 09/21/2023
ADOSH_2226 SHARP Application Form 09/21/2023
ADOSH_2227 Elevator Inspection (PEI) New Application Form 09/21/2023
ADOSH_2232 Boiler Inspector (PBI) Renewal Application 09/21/2023
ADOSH_2233 Variance Applications Forms 05/31/2024
ADOSH_2234 Alternative Clearance Forms 05/31/2024
ADOSH_2235 Accident and Investigation Request Forms 05/31/2024
ADOSH_2236 Inspector Complaint Forms 05/31/2024


Form Number Form Name Last Updated
Claims_0101 Employer Report of Injury Form 05/27/2022
Claims_0102 Worker’s and Physician’s Report of Injury Form 05/27/2022
Claims_0113 Employee Rejection of Terms Form 08/12/2016
Claims_0114 Employee Revocation of Rejection of Terms Form 08/23/2016
Claims_0120 Dependent Benefits Claim Form 06/07/2019
Claims_0121 Request to Change Doctors Form 06/07/2019
Claims_0122 Request to Leave State Form 06/07/2019
Claims_0123 Professional Employer Agreement Form 09/16/2016
Claims_0124 Bodily Fluids Work Exposure Form 09/16/2016
Claims_0407 Worker’s Report of Injury Form 05/27/2022
Claims_0446 Request for Hearing Form 06/07/2019
Claims_0528 Petition to Reopen Form 06/07/2019
Claims_0529 Petition for Rearrangement Form 06/07/2019
Claims_110A Annual Report of Income Form 08/12/2016
Claims_110B Notice of Intent to Suspend Form 08/12/2016


Form Number Form Name Last Updated
Labor_3303 Unpaid Wage Claim Form 05/27/2022
Labor_3304 Payment Compliance Complaint Form 02/25/2022
Labor_3305 Earned Paid Sick Time Claim Form 02/25/2022
Labor_3306 Youth Labor Complaint Form 02/25/2022
Labor_3307 EPST/Minimum Wage Retaliation Claim Form 02/25/2022
Labor_3325 Minimum Wage Claim Form 02/25/2022
Form Number Form Name Last Updated
Legal_4401 Public Records Request Form 04/01/2020
Legal_4402 Uninsured Employer Complaint Form 09/03/2020
Legal_4403 Employers Workers Compensation Insurance Inquiry Response Form 07/12/2017
Legal_4404 Petition for Attorney’s Fees 03/08/2018

Medical Resource Office

Form Number Form Name Last Updated
MRO_7711 Medical Treatment Preauthorization Form 09/27/2018

Special Fund

Form Number Form Name Last Updated
SpecFund_5413 Workers Supplemental Claim Form 413 08/12/2016
SpecFund_5525 Carrier's Notification of Scheduled Injury Time Loss 08/12/2016
SpecFund_5526 Workers Supplemental Claim For Compensation 01/18/2017
SpecFund_5527 Apportionment Settlement Letter 02/01/2021
SpecFund_5528 Vocational Rehabilitation Referral 06/07/2019