Instructions for Completing the WC-1007
Please enter the employee’s Social Security Number in the blanks at the upper right of the form.
“Purpose of Report” Section
The only blocks that should apply at the time you are completing this report are “more than 7 days of disability”; “injury resulted in death”; and “medical only.” If the employee will likely miss work for several days, check “more than 7 days of disability.” If the employee will probably see a doctor but will not miss work, check “medical only.” If you are reporting the claim for report purposes only, and the employee is neither missing work nor going to the doctor, write the letters “RPO” in this section. “RPO” stands for “report purposes only.”
Block 1. Date of Report
Enter the date that the WC-1007 is completed.
Block 2. Date of Injury and Time
Enter the date and time of day the injury occurred. If it is an occupational illness, enter the date that symptoms first appeared.
Block 3. Normal Starting Time Day of Accident
Self explanatory
Block 4. If Employee Back to Work, Give Date
If the employee did not miss work, enter “no lost time.”
Block 5. At Same Wage?
Leave this blank.
Block 6. If Fatal Injury, Give Date of Death
Self explanatory
Block 7. Date Employer Knew of Injury
Enter the date the employee first reported the injury, even if it was a verbal statement only.
Block 8. Date Disability Began
Enter the first day the employee missed work, not counting the date of the accident. If the employee did not miss any work, enter “no lost time.”
Block 9. Last Full Day Paid
Leave this blank.
Blocks 10, 11, 12, 13, 14, 15, 16, 17
Self explanatory
Block 18. Dept/Division Employed
Enter the name of the school where the employee works. If the employee is a Central Office employee, enter the department where he works. We do need a description more specific than “Lafayette Parish School Board.”
Blocks 19, 20, 21, 22
Self explanatory
Block 23. Part of Body Injured and Nature of Injury or Illness
Enter as specific information as you can about the injury itself. Include as many descriptions as you can. Here are some examples.
Description / Better DescriptionHurt foot / Bruised the top of the right foot
Pulled muscle in back / Pain in lower back; seems to be pulled muscle
Fell on right side / Bruised right shoulder, right arm, and right hip
Hit head / Has a small cut on the left side of the scalp above hairline
Block 24. If Occ. Disease-Give Date Diagnosed
“Occ” stands for “occupational.” It is probably best to leave this blank. We will be able to determine this date from the medical records.
Blocks 25, 26, 27, 28, 29, 30, 31, and 32
Self explanatory
Block 33. Wage Information
Leave this blank.