Workers’ Compensation

Workers’ Compensation is a no fault insurance system that provides for the payment of medical services, lost wages and other benefits when an employee:

  • suffers an injury;
  • develops an occupational illness; and/or
  • dies from an incident arising out of or in the course of employment.

There is no cost to employees for coverage; and employees receive benefits if their claim meets the requirements established by Ohio Revised Code.

Read the Introduction To Workers' Compensation   for more general information about the Ohio workers' compensation program.

The Hamilton County Workers' Compensation Handbook   has been compiled as a resource for county employees; but it is not meant to be an exhaustive guide to workers' compensation procedures. The Workers' Compensation program was established and is governed by Ohio Revised Code (Section 4123.01)  . Ohio Revised Code and Hamilton County Policy   prevail in the event of conflicts in this handbook.

View and Print Handbook  

Mission Statement of the Workers' Compensation Program
for Hamilton County Employees...

Hamilton County advocates an interactive partnership to promote a healing process focused on realistic recovery leading to successful return to work.

Forms

The forms listed below are those used most often in processing workers' compensation claims. To use these forms you can:

  • Click below, complete online and print OR print and complete in ink
  • Contact the Hamilton County Workers' Compensation Specialist
  • Contact your Departmental Workers' Comp Liaison
  • Bureau forms are available by contacting your Bureau representative or Managed Care Organization (MCO) claims specialist.

Employee Initiated Forms
Incident Only Report Form Completed by an employee to report a work related incident when no medical attention is sought 
HamCo044 - First Report of an Injury, Occupational Disease or Death FROI-1
Bureau form 1101 		Completed by an employee to report a work related incident when medical treatment is sought
HamCo047 - Authorization to Release Medical Information
Bureau form C-101		 Completed by an employee reporting an incident allowing retrieval of claim related medical documents
HamCo048 - Salary Continuation
Bureau form C-55e		 Completed by an employee reporting an incident providing mandatory information regarding payment of wages
HamCo049 - Physicians Report of Work Ability
Bureau form Medco-14		 Completed by each treating physician and required for an employee to return to work
Supervisor Initiated Forms
HamCo045 - Hamilton County Supervisor Investigation Form Completed by the acting supervisor on duty at the time of an incident whether or not medical attention is sought
HamCo046 - Hamilton County Statement of Witness to the Incident Form Completed by any and all witnesses to an incident reported by an employee whether or not medical attention is sought
BUREAU FORMS (Most commonly used by employees):
C-84: Request for Temporary Total Compensation: used by the employee to request compensation from the Bureau
C-86: Motion: used by the employee to request additional allowances be added to an allowed claim
C-94A: Wage Statement: Used to report wages to the Bureau
SH-12 - Sharps Injury Form - Needlestick Report Completed by an employee or supervisor within 5 days of injury by a needlestick or other "sharp"

Employee Rights and Responsibilities

The Employee Action Step Timeline/Checklist is a resource to help employees follow the appropriate steps for workers' compensation claims.

Initial Action Steps - employee procedure upon notice of a work related incident.

Medical Treatment - employee procedure for seeking medical attention after a work related incident.

Return to Work - options available to provide injured workers with a safe return to work after a work related incident.

Vocational Services - individualized and voluntary programs for eligible injured workers needing assistance in safely returning to work or in retaining employment after a work related incident.

Compensation - employee eligibility for compensation for lost wages due to a work related incident.

Motor Vehicle Accident - employee procedure when involved in a motor vehicle accident.

Form Summary - forms identified in the employee section.

Supervisor/Department Head Responsibilities

The Supervisor Action Step Timeline/Checklist is a resource to help supervisors follow the appropriate steps for workers' compensation claims.

Initial Action Steps - supervisor/department head procedure upon notice of a work related incident.

Medical Treatment - supervisor/department head procedure if an employee seeks medical attention because of a work related incident.

Fatality or Multiple Injury Incident - OAC mandate in the event of a fatality or multiple injury incident due to a work related incident.

Vocational Services - individualized and voluntary programs for eligible injured workers needing assistance in safely returning to work or in retaining employment after a work related incident.

Compensation - supervisor/department head procedure to assist employees with eligibility for compensation for lost wages due to a work related incident.

Form Summary - forms identified in the supervisor/department head section.

Department/Agency Workers' Comp Liaison Role

Initial Action Steps– dept/agency workers’ comp liaison procedure upon notice of a work related incident.

Medical Treatment- dept/agency workers’ comp liaison procedure if an employee seeks medical attention because of a work related incident.

Return to Work - dept/agency workers’ comp liaison procedure when an employee returns to work after a work related incident.

Compensation - dept/agency workers’ comp liaison procedure to assist employees with eligibility for lost wages due to a work related incident.

Form Summary – forms identified in the dept/agency workers’ comp liaison section.

The Managed Care Organization

Initial Action Steps - how the managed care organization proceeds upon notice of a work related incident.

Medical Treatment - how the managed care organization assists an employee with medical treatment after a work related incident.

Return to Work - how the managed care organization assists in returning an employee to work after a work related incident.

The Ohio Bureau of Workers' Compensation

Initial Action Steps - how the Ohio Bureau of Workers' Compensation proceeds upon notification of a work related incident.

Compensation - how the Ohio Bureau of Workers' Compensation orders compensation.

Physician of Record

Initial Action Steps - how the physician of record proceeds upon treatment of the initial injury of a work related incident.

Medical Treatment - the physician of record's obligation to submit reports related to treatment for a work related incident.

Return to Work - how the physician of record guides the return to work of an employee after a work related incident.

Recording and Records Retention - the physician of record's obligation to retain records for a work related incident.

Compensation - how the physician of record assists the injured worker obtain compensation for lost wages due to a work related incident.

Third Party Administrator

Initial Action Steps - how the third party administrator proceeds upon notice of a work related incident.

Compensation- how the third party administrator proceeds upon notice that an injured worker is seeking compensation for a work related incident.

Adjudication - how the third party administrator proceeds in matters needing adjudication before the Bureau and the Industrial Commission.

The Industrial Commission of Ohio

Initial Action Steps - what the Industrial Commission of Ohio does.

Adjudication - the administrative appeals process of the Industrial Commission of Ohio.

The Ohio Attorney General's Office

Adjudication - the administrative appeals process of the Ohio Attorney General's Office.