5 Steps To Fill Out A Dshs Stop Work Form

Quick Links :

Filling out a DSHS Stop Work Form is a crucial step in reporting work-related injuries or illnesses to the Washington State Department of Social and Health Services (DSHS). This form is used to notify the DSHS of a worker's injury or illness, which can affect their eligibility for benefits. In this article, we will guide you through the 5 essential steps to fill out a DSHS Stop Work Form accurately and efficiently.

Understanding the Importance of Reporting Work-Related Injuries

Reporting work-related injuries or illnesses is essential for ensuring that workers receive the necessary benefits and support. Failure to report an injury or illness can result in delayed or denied benefits, which can lead to financial hardship for the worker. By filling out the DSHS Stop Work Form correctly, you can ensure that the DSHS receives the necessary information to process the worker's claim efficiently.

Step 1: Gather Required Information

Before filling out the DSHS Stop Work Form, gather all the necessary information about the worker and their injury or illness. This includes:

• The worker's name, address, and contact information
• The date and time of the injury or illness
• A detailed description of the injury or illness
• The name and address of the employer
• The worker's job title and duties
• Any medical treatment received

Step 2: Fill Out Section 1 - Worker's Information

Section 1 of the DSHS Stop Work Form requires information about the worker. Fill out the following fields:

• Worker's name
• Address
• City
• State
• ZIP code
• Date of birth
• Social Security number (optional)

Make sure to fill out this section accurately, as any errors can delay the processing of the worker's claim.

Step 3: Fill Out Section 2 - Injury or Illness Information

Section 2 of the form requires information about the injury or illness. Fill out the following fields:

• Date of injury or illness
• Time of injury or illness
• Description of injury or illness
• Body part affected
• Type of injury or illness (check all that apply)

Provide as much detail as possible about the injury or illness, including any medical treatment received.

Step 4: Fill Out Section 3 - Employer Information

Section 3 of the form requires information about the employer. Fill out the following fields:

• Employer's name
• Address
• City
• State
• ZIP code
• Employer's telephone number
• Employer's fax number (optional)

Make sure to fill out this section accurately, as any errors can delay the processing of the worker's claim.

Step 5: Review and Sign the Form

Review the completed form for accuracy and completeness. Sign and date the form, and provide the worker's signature if possible. If the worker is unable to sign, provide an explanation for their inability to do so.

Tips for Filling Out the DSHS Stop Work Form

• Use black ink to fill out the form, and make sure to print clearly.
• If a question does not apply, write "N/A" in the space provided.
• Do not leave any fields blank, as this can delay the processing of the worker's claim.
• Make a copy of the completed form for the worker's records.

By following these 5 steps, you can ensure that the DSHS Stop Work Form is filled out accurately and efficiently. Remember to review the form carefully before submitting it to the DSHS.

Additional Resources

• Washington State Department of Social and Health Services (DSHS) website:
• DSHS Stop Work Form instructions:

We hope this article has provided you with the necessary guidance to fill out the DSHS Stop Work Form accurately and efficiently. If you have any questions or concerns, please do not hesitate to reach out to us.