Tina Kotek, Governor 

                               BULLETIN NO. 101 (Revised) 
                                   May 28, 2024 

  TO:            Workers’ compensation insurers and self-insured employers 
  
 SUBJECT:        Forms required for processing initial claims of occupational injury or disease 
  
 EFFECTIVE:      June 6, 2024 
  
 This bulletin provides or describes forms that meet the requirements of Oregon Revised 
 Statute (ORS) 656.265 and Oregon Administrative Rules (OAR) 436-060-0010, 436-060-
 0011, and 436-060-0015:  
  
  •   Form 801, “Report of Job Injury or Illness” 
  •   Form 3283, “A Guide for Workers Recently Hurt on the Job” 
  •   Form 1138, “What happens if I’m hurt on the job?” 
  
 The division is republishing this bulletin to provide a revised Form 3283. The form was 
 revised to change the term “physician assistant” to “physician associate,” as a result of 
 House Bill 4010 (effective June 6, 2024). No other changes have been made to the form. 
 This bulletin replaces Bulletin 101 dated Aug. 24, 2022.  
  
 There is no immediate need to reprint or restock Form 3283. The division encourages use of 
 the revised form when you next update your system templates or need to restock. 
  
 Printing and distribution of “Report of Job Injury or Illness,” Form 801 
 A.  Insurers must provide copies of Form 801 to their insured employers. Employers must 
    provide Form 801 to injured workers (or anyone acting on the worker’s behalf) immediately 
    upon request, or upon receiving notice or knowledge of an accident that may involve a 
    compensable injury.   
  
 B.  On all reporting forms, print the name, address, and phone number of the insurer, self-
    insured employer, and service company, if any.  
  
    Note: Some of the information on Form 801 (and the Federal Form 301) is subject to release 
    by the employer to authorized employee representatives upon request. Information must be 
    made available in such a way that confidentiality of the injured worker is protected 
    regardless of the form used.    

  350 Winter St. NE  800-452-0288  workcomp.questions@dcbs.oregon.gov             wcd.oregon.gov 
  P.O. Box 14480     503-947-7585 
  Salem, OR 97309 
  

Bulletin 101 
Page 2 

“A Guide for Workers Recently Hurt on the Job,” Form 3283 
Insurers must provide Form 3283 to their insured employers. The employer must provide Form 
3283 to the worker at the time a worker files a claim for workers’ compensation benefits. An 
insurer may revise the form to include its name and phone number in the heading, at the end, or 
in the paragraph “What if I have questions about my claim?” Form 3283 may be printed on the 
back of Form 801.  
 
“What happens if I am hurt on the job?” Form 1138 
The insurer must provide the pamphlet (Form 1138) to every injured worker who has a disabling 
injury or disease claim with the first time-loss check or earliest written correspondence. 
Distribution of Form 1138 for a nondisabling claim is not required unless requested by the 
worker. The division will furnish Form 1138 to insurers upon request, limited to a four-month 
supply. Contact the division at 503-947-7627 to request copies of the pamphlet. 
 
You can download the forms from the division’s website: 
https://wcd.oregon.gov/forms/Pages/forms.aspx. If you have questions about this bulletin, 
contact a benefit consultant by email, workcomp.questions@dcbs.oregon.gov, or by phone, 800-
452-0288 (toll-free).  
  
 Matt West, Interim Administrator 
 Workers’ Compensation Division 
 
Attachments:  Form 801 (Rev. 1/21) 
              Form 3283 (Rev. 6/24) 
 
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