Blank Official 122 Utah Form

The Official 122 Utah form, known as the Employer's First Report of Injury or Illness, is similar to several other documents used in workers' compensation and injury reporting. Each document serves a specific purpose in the process of reporting workplace injuries or illnesses. Here’s a list of eight documents that share similarities with the Official 122 form:

• OSHA Form 300: This form is used to log work-related injuries and illnesses. Like the Official 122, it requires detailed information about the incident, including the nature of the injury and the employee involved.
• OSHA Form 301: This form is a more detailed incident report that follows the OSHA Form 300. It provides additional information about the circumstances of the injury, similar to how the Official 122 captures specifics about the injury and treatment.
• Workers' Compensation Claim Form: This form is used by employees to file a claim for benefits after a workplace injury. It requires similar information regarding the injury and its impact on the employee's ability to work, akin to the details requested in the Official 122.
• Incident Report Form: Many employers use this internal document to report workplace accidents. It collects information about the incident, similar to the Official 122, but may not be standardized across different jurisdictions.
• Power of Attorney Form: For granting authority to another individual, refer to our important Power of Attorney document resources to ensure your wishes are respected.
• Employee Injury Report: This document is often filled out by employees to document their own injuries. It parallels the Official 122 by capturing the details of the injury, including the date, time, and nature of the incident.
• Medical Treatment Authorization Form: This form is used to authorize medical treatment for injured employees. It shares similarities with the Official 122 in that it requires information about the injury and the healthcare provider involved.
• Return to Work Form: After an injury, employees may need to submit this form to confirm their ability to return to work. It often references the initial injury report, similar to how the Official 122 is used to track the progress of the claim.
• State-Specific Workers' Compensation Forms: Each state may have its own forms for reporting injuries and filing claims. While the specifics may vary, these forms typically require similar information as the Official 122 regarding the injury and the employee's status.

Understanding these documents helps in navigating the workers' compensation process effectively. Each form plays a role in ensuring that injuries are reported accurately and that employees receive the benefits they are entitled to.

What is the Official 122 Utah Form?

The Official 122 Utah Form, also known as the Employer's First Report of Injury or Illness, is a document that employers must file when an employee experiences a work-related injury or illness. This form is essential for initiating a workers' compensation claim. It collects information about the employer, the injured employee, and the details of the incident. Importantly, filing this form does not mean the employer admits liability for the claim.

When should the Official 122 Utah Form be submitted?

The form must be submitted within seven days after the injury or illness occurs, or after the employee notifies the employer about it. This requirement applies when the incident leads to medical treatment, loss of consciousness, loss of work, or any restrictions on work duties. Additionally, if the injury later results in death, a subsequent report must be filed with the Labor Commission.

What information is required on the form?

The Official 122 Utah Form requires detailed information, including:

1. Employer's name, address, and Federal Employer Identification Number (FEIN).
2. Employee's name, address, date of birth, and Social Security Number.
3. Details of the injury or illness, including the date, time, and description of what happened.
4. Medical treatment information and the name of the healthcare provider.

It's crucial to fill out all sections accurately to avoid delays or issues with the claim.

What happens if the form is not filed on time?

If the Official 122 Utah Form is not filed within the required timeframe, the employer may face penalties. Failure to submit the form can result in a Class C misdemeanor and may lead to civil penalties. Moreover, if the report is not filed within 180 days of the injury or illness, the employee may lose the right to file a claim for workers' compensation benefits related to that incident.

• Form Purpose: The Official 122 form is used to report workplace injuries or illnesses to the Labor Commission in Utah.
• Timeliness: Employers must submit the form within seven days of the injury or illness occurrence or the employee’s notification.
• Detailed Information: Complete all sections thoroughly to avoid delays or the need for additional correspondence.
• OSHA Log Number: Include the employer-assigned Case Number from OSHA’s 300 Injury Log, reflecting the year of the injury.
• Employee Information: Provide accurate details about the injured employee, including their name, address, and social security number.
• Medical Treatment: Indicate the type of medical treatment received and whether any safety equipment was used during the incident.
• Record Keeping: Maintain copies of the report for the employer’s records, and provide copies to the employee and the insurance carrier.
• Legal Obligations: Failure to file the report or provide a copy to the employee can result in legal penalties.
• Fraud Warning: Be aware that submitting false information can lead to criminal charges and penalties.

• Do ensure that all required fields are filled out accurately and completely to avoid delays.
• Do submit the form within seven days of the injury or illness occurrence to comply with Utah law.
• Do provide the correct employer name and FEIN number, as it must match official records.
• Do keep a copy of the submitted form for your records, as it is an important document.

• Don't enter data in the shaded areas of the form, as this could lead to confusion or errors.
• Don't omit any details about the injury or illness; thorough descriptions are essential.
• Don't forget to inform the injured employee of their rights and obligations under Utah’s Workers’ Compensation Act.
• Don't delay filing if you dispute the claim; you must still submit the report even if there are disagreements.