Workers’ Compensation C-4 Form

Shook & Stone - Nevada Work Comp Lawyers

C-4 From – How to Avoid Mistakes When Completing the Form C-4

When handling workers’ compensation claims, we often encounter improper entries on the C-4 form. Any mistakes you make on the C-4 form at the start of the claim can result in complications for you, the injured worker, that remain throughout the claim.

However, by following a few simple tricks, you can easily get through this barrier and fully recover all the benefits you need under Nevada’s workers’ compensation system.

Download the Form C-4 here

Demographics: Simple but Important

The first part of the form is pretty straightforward: do be sure to complete all the basics, i.e., name, address, birth date, height, weight, etc. Most people get this part right on there C-4 Form, and of course, something like your gender will hardly cost you your claim.

When we get down to the critical stuff, things can get hairy. The eighth line down is where the vital information starts.

You may find a copy of this form located here. https://dir.nv.gov/uploadedFiles/dirnvgov/content/WCS/C-4%20revised%208-12-2021%20.pdf

Nevada C-4 Form

The Date of Injury – Ensure that this is the exact day you were injured and hopefully the day you notified your employer about your injury!

Judges will often believe that an injury did not occur because the injured employee casually put down facts that an aggressive defense attorney later refuted.

Date Employer notified – Things start to get complicated on the C-4 Form here. The rules state you are to report your injury “as soon as practically possible, but within seven days.”

The time frame is so short because you have the burden of proving your injury occurred at work instead of at home. If you wait, it becomes to prove.

Let’s assume you hurt your back and then go home, hoping that you can sleep it. When you wake up the next day, if your back is still in severe pain, one could argue that your back pain resulted from you sleeping poorly. Therefore, how do you prove that you injured your back at work?

The most critical piece of advice? Report your injury immediately!

Even if you think you will recover without going to the doctor. You cannot turn back time. Without a report, you have no claim. According to Nevada law, a C-1 form, “Notice of Injury or Occupational Disease Incident Report”, needs to be completed and returned to your employer for all occupational injury/disease claims.

If your employer doesn’t have a C-1 form handy or if you cannot print one yourself, write it on anything like a napkin or a scrap of paper if needed.

Taking Care of the Rest: What Else are You Responsible for Completing on the C-4 Form?

Nevada C-4 Form Part B

Fill out the rest of C-4 Form Carefully and with accurate dates, data, and a witness to the accident if applicable.

Last Day of Work After Occupational Injury/Disease – If you were injured and unable to work, that will be your last day.

Supervisor to Whom Injury was Reported – Your supervisor or whoever is in charge of you.

Address or Location of Accident – Where were you? Recording the location is essential. If you were working at the time, you got injured, but somewhere else, there may be a third-party claim for compensation also.

What were you doing at the time of the accident? – Explain as accurately as possible what you were doing when the accident took place.

How did this injury or occupational disease occur? – Be very specific. The devil is in the details here. You’ve got a larger box to give ample information, so list every detail! Leaving out facts in this area can cost you your claim. Be sure to identify what caused you to injure yourself specifically. Whether there was a loose tile, a wrinkle in the carpet or you were hurrying to finish something at work and tripped, make sure you record it. A risk associated with your employment resulting in your injury needs to be identified. Your claim will probably be accepted if you can do that. An “I don’t know” in this box is easy to refute, and your claim will likely be denied.

When did you first have knowledge of your occupational disease and its relationship to your employment? – As with the question above, be specific. Explain the course of events that led you to believe that you are suffering from an occupational disease. This question is important because there is a statute of limitations of 7 days that begins when you first suspected that you are suffering from a work-related illness.

Witnesses to the Accident – List every person that witnessed the accident. If you are unsure if they witnessed the accident, say you are unsure if they saw it or not, and list them out.

Nature of Injury – What was it? A sprain, strain, contusion, bruise, laceration etc.?

Parts of Body Injured or Affected – Make sure you list all the body parts that may be injured. It is challenging to add additional body parts later, so if you think it hurts, list it!

Date, Sign, and List the Facility you went to.

The last half of the C-4 Form is filled out by the doctor. Make sure that you review his entries before you leave the hospital. Many doctors are in a rush and can make mistakes on the form.

Remember that you didn’t want to be injured in the first place. You don’t want to return to the hospital due to a clerical error. Therefore, ensure that the doctor has fully completed the rest of the form.

  • Make sure that your doctor lists the same body parts that you did.
  • Make sure that your doctor links your injury to your work.
  • If your doctor gives you time off, ensure he/she lists the from and to dates.
  • If there are restrictions, ensure that they are clear and concise.
  • If there’s a follow-up, when will your follow-up be and where?
  • Last but not least, make sure that the doctor signs the form. The form is not valid unless it is signed.

By following these tricks for the C-4 Form, you will find that you can avoid many common pitfalls for injured workers in Nevada. We have only covered the topic of workplace accidents here.

As always, if you require an experienced, aggressive personal injury attorney in Nevada workers’ compensation procedures, our assessments are free, and we will be happy to answer all of your questions.

Give us a call at (702) 570-0000 or fill out the form for a free consultation.