Wyoming Administrative Code
Agency 053 - Workforce Services, Department of
Sub-Agency 0021 - Workers' Compensation Division
Chapter 4 - INJURY REPORT PROCEDURE
Section 4-2 - Contents of the Worker's Report

Universal Citation: WY Code of Rules 4-2

Current through July 13, 2024

The report shall be on a form provided by the Division, available from the Division or employer, and shall contain the following information:

(a) The worker's full name, mailing address, telephone number and Social Security Number;

(b) The worker's birth date, sex, marital status and number of dependents;

(c) The employer's full name, address and telephone number;

(d) The worker's date of hire and job title;

(e) A statement of whether the worker is a regular worker, volunteer, inmate, a governmentally subsidized work experience program participant, or has an interest in the business as owner, partner, or corporate officer;

(f) The worker's current monthly earnings;

(g) The date, time and location of the accident or injury;

(h) A statement of how the injury occurred, including what the worker was doing at the time and what objects or substances caused the injury;

(j) A statement identifying the parts of the worker's body affected by the injury;

(k) The name(s) of any witness(es) to the events causing the injury;

(l) The names and addresses of all health care providers who have treated or provided medical services to the worker for the injury being reported;

(m) If the report is prepared by a person other than the worker, the full name, address and telephone number of the person preparing the report, and that person's relationship to the worker;

(n) Such additional information as the Division deems appropriate; and

(o) The report form shall be signed and dated by the worker, or his personal representative if the worker is incapacitated.

(i) Acceptance of legal recognition of electronic records; electronic signatures and electronic contracts (W.S. § 40-21-107) includes:
(A) A record or signature may not be denied legal effect or enforceability solely because it is in electronic form.

(B) A contract may not be denied legal effect or enforceability solely because an electronic record was used in its formation.

(C) If a law requires a record to be in writing, an electronic record satisfies the law.

(D) If a law requires a signature, an electronic signature satisfies the law.

Disclaimer: These regulations may not be the most recent version. Wyoming may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.