104 NOTICE OF INJURY; EMPLOYEE OR REPRESENTATIVE ACTION

104.1 An employee shall give written notice of an injury or recurrence of disability, or an employee's representative shall give notice of an employee's death, to the employee's immediate supervisor within thirty (30) days of the injury, recurrence of disability, or death pursuant to Section 2319 of the Act and this chapter.

104.2 Notice shall be effected upon the immediate supervisor's receipt of a completed Form 1, Form 4, and Form 5 within thirty (30) days of the injury, recurrence of disability or death, or within such greater period permitted under Section 2319 of the Act or § 104.6 of this chapter.

104.3 Form 1 shall:

1. (a) Be in writing;
2. (b) State the name and address of the employee;
3. (c) State the time, date, and location where, the injury, recurrence of disability or death occurred;
4. (d) Describe the activities the employee was engaging in at the time of the injury or recurrence of disability;
5. (e) State the cause, mechanism and nature of the injury, or if a recurrence of disability, the causal relationship to the original injury, or in the case of death, the employment factors believed to be the cause;
6. (f) State the employee's official job title, grade and step, duties, shift, number of hours scheduled to work per day, and days scheduled to work per week;
7. (g) State the employee's benefits deductions, if any, as listed in § 128 of this chapter;
8. (h) State whether injury was caused by a third party; and
9. (i) Be signed by, and contain the address of, the individual giving the notice.

104.4 The employee or employee's representative shall complete and submit:

1. (a) Form 4 – Employee Authorization for Release of Medical Records; and
2. (b) Form 5 – Employee Authorization for Release of Earnings.

104.5 “Actual knowledge” under Section 2319(b)(1) of the Act means, within thirty (30) days of the injury, that:- (a) The employing agency prepared a written report in the regular course of duty that met the requirements of Sections 2319(a)(5), 2319(a)(6) and 2319(b)(1) of the Act; or

- (b) The Program is in possession of a written report by the employing agency prepared in the regular course of duty, that meets the requirements of 2319(a)(5), 2319(a)(6), and 2319(b)(1) of the Act.104.6 Exceptions for providing timely adequate notice under Section 2319(b)(2) of the Act may be granted only where the Chief Risk Officer or his designee finds a satisfactory reason the notice could not be given.104.7 Notice of aggravated injury shall be provided pursuant to §§ 104.1 through 104.6 of this chapter within thirty (30) days from the discrete event or occurrence that aggravated, worsened or exacerbated the employee’s pre-existing disease, illness or condition.104.8 Notice of recurrence of disability shall be provided pursuant to §§ 104.1 through 104.6 of this chapter within thirty (30) days from the date of recurrence of disability.104.9 Notice of latent disability shall be provided pursuant to §§104.1 through 104.6 of this chapter within thirty (30) days of the earlier of:- (a) The date on which the employee first sought medical attention for the employee’s condition and was aware or, by the exercise of reasonable diligence should have been aware, of the causal relationship between the claimant’s condition and employment, whether or not the employee ceased work; or

- (b) The date on which the employee became disabled and was aware or, by the exercise of reasonable diligence should have been aware, of the causal relationship between the claimant’s disability and employment.

SOURCE: Final Rulemaking published at 28 DCR 2307 (May 22, 1981); as amended by Final Rulemaking published at 29 DCR 5196 (November 26, 1982); as amended by Final Rulemaking published at 47 DCR 7484 (September 15, 2000); as amended by Emergency and Proposed Rulemaking published at 57 DCR 9540 (October 8, 2010)[EXPIRED]; as amended by Final Rulemaking published at 57 DCR 12224, 12225 (December 24, 2010); as amended by Final Rulemaking published at 59 DCR 8766, 8768 (July 27, 2012); as amended by Final Rulemaking published at 64 DCR 6325 (July 7, 2017).