Florida Regulations 69L-3.004

• Amendments effective 1-10-05

(1) An employer shall record all industrial injuries and diseases as follows:

(a) For a first aid case that is not required to be reported to the claimshandling entity, the employer shall maintain a record of the following information regarding the injury or illness:

1. The employee's name. 2. Social security number or other identifying number pursuant to paragraph 69L- 3.003(3)(b), F.A.C. 3. Date and time of the accident or injury. 4. Occupation of the employee. 5. Who the injury was reported to and when. 6. Description of the accident or illness, including the cause of injury. 7. Injury or illness that occurred and affected body part. 8. Location address of the injury if different than the employer's address.

(b) For a medical only case, lost time case, or death case, the employer shall complete Form DFS-F2-DWC-1, as adopted in Rule 69L- 3.025, F.A.C., or report the information regarding the injury or illness by other means as provided by the claims-handling entity.

(2) An employer shall report on Form DFS-F2-DWC-1, as adopted in Rule 69L- 3.025, F.A.C., information concerning an industrial injury or disease to its claimshandling entity as follows:

(a) An employer shall report all cases, except first aid cases, to its claimshandling entity within 7 days after the employer's knowledge of an industrial injury or disease. The employer shall not delay reporting the injury or illness to the claims-handling entity because the employee's signature is unavailable. (b) If a first aid case later becomes a medical only or lost time case, the employer shall report the injury or illness to the claims-handling entity within 7 days after the employer's knowledge of the change in status. (c) When an employer submits to its claims-handling entity Form DFS-F2- DWC-1, the employer shall provide a copy of the form to the employee or the employee's estate. If the information required by Form DFS-F2-DWC- 1, as adopted in Rule 69L- 3.025, F.A.C., is reported to the claims-handling entity by other means the claims-handling entity shall provide the employee and the employer a completed Form DFS-F2-DWC-1, within three (3) business days of the claims-handling entity's notification of the injury or illness. Form IA-1 may be sent to the employee and employer, if the claims-handling entity is electronically sending the first report of injury information required in Rule 69L- 3.0045, F.A.C., to the Division. (d) In addition to the reporting requirements pursuant to paragraph 69L- 3.004(2)(a), F.A.C., if an injury or illness results in the employee's death, the employer shall give notice by telephone or by other means to the Division of Workers' Compensation within 24 hours of the employer's knowledge of the death. The mailing address for reporting of death cases is: Department of Financial Services, Division of Workers' Compensation, Occupational Safety and Health Unit, 200 East Gaines Street, Tallahassee, Florida 32399-4222. The telephone number for reporting death cases is (800) 219-8953, (850) 413-1611 or by facsimile at (850) 922-0024.

(3) Employers shall retain a record of all information required under this section for not less than 2 years and 6 months after the date the injury or illness is reported to the employer.

Specific Authority 440.35, 449.591, 440.185(2), (5), (9), 440.19 FS. Law Implemented 440.185(2), (3), (5), 440.207(2), 440.35 FS. History-New 8-30-79, Amended 12-23-80, 11-5-81, 6-12-84, Formerly 38F-3.04, Amended 1-1-87, 4-11-90, 1-30-91, 11-8-94, Formerly 38F-3.004, 4L-3.004, Amended 1-10-05.