SU-16 Workers' Compensation Lost Workdays Report

Last Update: 01/03

This form is required by Risk Management (Workers' Compensation Division) for OSHA reporting and to stop benefit payments. Please submit when the employee has lost one or more full calendar days of work or had restricted work activity due to a work-related injury or illness. This form will be submitted to Risk Management; a copy will be sent to the submitter's electronic mail address.

Employee's Information
Employee Name:
Department:
Date of Injury:
Days Away from Work
Enter the number of all calendar days on which the employee could not work because of occupational injury or illness. All calendar days include weekends and holidays during lost time. The number of lost days should not include the day of injury or day of return. Employers are no longer required to count days away beyond 180 days.
Total Lost Days (Full days only):
Date Returned to Work:
Restricted Work Activity
Enter the number of all calendar days on which the employee was restricted because of injury or illness: the employee was assigned to another job on a temporary basis; or the employee worked at a permanent job less than full time (Dr. appointments, etc.); or the employee worked at a permanently assigned job but could not perform all duties normally associated with it. Employers are no longer required to count restricted days beyond 180 days.
Total Restricted Days: (List as full days)
Submitter's Information
Submitted by:
E-mail (please include hostname, e.g. hf.gwi@forsythe):
Phone:
If an employee has a recurrence of lost days due to this injury, please notify the appropriate Workers' Compensation administrator to establish start of Workers' Compensation Salary payment program: (1) If the date of injury is during the period 11/01/98 to 8/31/00, notify REM at (800) 347-2509. (2) All other dates of injury notify Zurich North America Claims at 877-246-3478 Submit additional lost time report upon employee's return to work.