Washington Report of Accident (ROA) Workplace Injury, Accident or Occupational Disease

State:
Washington
Control #:
WA-SKU-3886
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PDF
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Report of Accident (ROA) Workplace Injury, Accident or Occupational Disease
The Washington Report of Accident (ROA) Workplace Injury, Accident or Occupational Disease is a report required by the Washington State Department of Labor & Industries (L&I) for all workplace injuries, accidents, and occupational diseases. It is a form mandated by the state of Washington for employers to provide when an employee is injured, becomes ill, or is exposed to a hazardous work environment. The Washington Report of Accident (ROA) must be completed by the employer and submitted to L&I within four days of the date of the incident. It must include the date, time, and location of the incident, as well as a description of the incident and the injuries sustained. It must also include any witness information and a description of any safety precautions related to the incident. The Washington Report of Accident (ROA) can be used to request workers’ compensation benefits or to dispute any claims made to L&I. It is also used to investigate and determine fault for workplace injuries and illnesses. There are three types of ROA: Workplace Injury, Accident, and Occupational Disease. A Workplace Injury ROA is used to document workplace injuries, such as slips, trips, falls, or cuts. An Accident ROA is used to document accidents, such as vehicle accidents, machinery malfunctions, or explosions. An Occupational Disease ROA is used to document occupational diseases, such as asbestos exposure or repetitive strain injuries.

The Washington Report of Accident (ROA) Workplace Injury, Accident or Occupational Disease is a report required by the Washington State Department of Labor & Industries (L&I) for all workplace injuries, accidents, and occupational diseases. It is a form mandated by the state of Washington for employers to provide when an employee is injured, becomes ill, or is exposed to a hazardous work environment. The Washington Report of Accident (ROA) must be completed by the employer and submitted to L&I within four days of the date of the incident. It must include the date, time, and location of the incident, as well as a description of the incident and the injuries sustained. It must also include any witness information and a description of any safety precautions related to the incident. The Washington Report of Accident (ROA) can be used to request workers’ compensation benefits or to dispute any claims made to L&I. It is also used to investigate and determine fault for workplace injuries and illnesses. There are three types of ROA: Workplace Injury, Accident, and Occupational Disease. A Workplace Injury ROA is used to document workplace injuries, such as slips, trips, falls, or cuts. An Accident ROA is used to document accidents, such as vehicle accidents, machinery malfunctions, or explosions. An Occupational Disease ROA is used to document occupational diseases, such as asbestos exposure or repetitive strain injuries.

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FAQ

Right to get medical care needed for treatment at no cost. Right to get time loss benefit payment if unable to work for more than 3 days. Right to turn down (decline) ?light duty? work offer unless approved by your doctor. Right to get a permanent partial disability payment if your injury is permanent.

L&I or your self-insured employer must receive your Report of Accident within 1 year of your injury date to file a claim. We must receive it within two years from the date of your doctor's diagnosis for occupational disease claims.

Filling out the Report of Accident (ROA)

After an injury or illness occurs, your employer must: Provide a workers' compensation claim form to you within one working day a work-related injury or illness is reported. Return a completed copy of the claim form to you within one working day of receipt.

Important: Employers by law must report to L&I the death or in-patient hospitalization of any worker (within 8 hours) and any non-hospitalized amputation or loss of eye (within 24 hours) due to an on-the-job injury by calling 1-800-423-7233.

If you have an accident in the workplace, you should: make sure you record any injury in the 'accident book' if need be, make sure your employer has reported it to the HSENI. check your contract or written statement of employment for information about sick or accident pay.

Call 1-800-423-7233, option 1 To report an on-the-job fatality, in-patient hospitalization, amputation, or loss of an eye, call 1-800-423-7233.

More info

If you are an injured worker, ask your medical provider for a copy of this form. Include a complete diagnosis and appropriate Common Diagnostic Codes (ICD codes).Clarify a specific body site and the definition of the injury. Instructions: Complete this form as soon as possible after an incident that results in serious injury or illness. Complete the Report of Accident (ROA) form. The best way to file a claim is to see a doctor and in their office, you and they together will fill out the Report of Accident (ROA) form. (Workplace Injury, Accident or Occupational. Disease), which begins the claim process. The provider will help the worker complete a Report of Accident. Describe in full how the accident occurred (Relate the events which resulted in the injury or occupational disease.

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Washington Report of Accident (ROA) Workplace Injury, Accident or Occupational Disease