The DWC-1 is comprised of four basic sections.  These instructions will address each section separately and indicate what information is to be inserted in each block.  The basic sections can be considered as Employee Information, Injury Information, Employee Pay Information, and Unit Information.

SECTION 1 - EMPLOYEE INFORMATION

Blocks 1-8 - Basic information about the employee.  Be sure to include full name.  Much of this information is for statistical use by the Texas Department of Insurance, Division of Workers Compensation (DWC) and remains confidential.

Block 9 - Use the address where the employee receives mail.

Blocks 10-12 - Employee's family information.  Block 10 is for statistical use, while blocks 11 and 12 are used where necessary by the DWC.

Blocks 13-14 - Information on the Doctor who treated the injury (if any).  If no doctor treated the injury enter NONE. NOTE: Do not list the employees regular doctor if none was seen

SECTION 2 - INJURY INFORMATION

Block 15-16 - The date and time of the injury.  If claiming an injury from repetitive stress, place the date when the problem was identified and the employee was to seek medical attention.

Block 17 - Enter the date lost time began.  If the employee goes to the doctor and returns the same, or the next day, there is no lost time.  Also, if the employee is not restricted from work except for the day following the injury, there is no lost time.  Where there is no lost time, enter NONE or N/A.  If the employee is injured on a Friday, and is restricted from work until Monday, the lost time begins on Saturday.  On Monday, complete a DWC-6 returning the employee to work.

Blocks 18-19 - Identify the nature of the injury and body part affected.  use the Nature of the Injury and Body Part Guides (click here for the guides).

Block 20 - Describe the events, injury, and reasons as best as you can.  Use additional sheets if necessary.

Block 21 - Self explanatory.

Block 22 - The exact location where the injury occurred.

Block 23 - The exact street address where the injury occurred - as close as possible.  If a business site, provide the name of the business.

Block 24 - A specific object, substance or exposure that inflicted the injury.  Such as "knife," or "glass pipette."

Block 25 - A list of witnesses if any.  Also provide addresses and phone numbers if possible. NOTE: we may ask for statements from these witnesses.

Block 26 - an estimated return to work date.  If unknown, enter UNK.  If there is no lost time, enter the next day or the same day as the injury if the employee returned to work the same day.

Block 27 - self explanatory.

Block 28 and 29 - Enter the supervisor's name and the date the injury was reported to the supervisor/administrative person completing the first report - whichever was earlier.

SECTION 3 - EMPLOYEE PAY INFORMATION

Block 30 - 33 -Self explanatory

Block 34 - Employee's title code

Block 35 - Occupation, not title of the employee. 

Block 36 - Gross hourly pay.

Block 37 - Numbers of hours worked in a normal work week.

Block 38 - Gross amount paid on the last pay check and the number of hours and days worked during this period.

SECTION 3 - UNIT INFORMATION