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Advisory 97-06


The Executive Director, under the authority granted by the Texas Labor Code, Section 402.042 hereby adopts:

Form number TWCC-41 E/S (Revised 9/97), for use before the Commission on or after November 1, 1997. The revised form and instructions for the use of the new form are attached.

The revised form, worded in English and Spanish, is to be filed with the Commission by, or on behalf of, the injured employee. The revisions include: supplementing information regarding the worker's race and ethnicity as required by the Texas Labor Code; minor changes in the wording and layout of the form; deletion of the "Carrier's Claim Number" because it is not necessary for processing by the Commission and is not readily known by the worker; deletion of "Date of Birth" because that data is captured on the Employee's First Report of Injury; and clarification that the form can be filed with the field office handling the claim or with the Commission's Austin (Central) office.

Form TWCC-41 E/S is to be printed as a single page form (form on front and instruction on reverse). Existing stocks of the previous version of the form may be used until November 1, 1997. The new form must be used on and after November 1, 1997 to support the capture of the additional data. Questions concerning the use of the new form should be directed to the Commission's Workers' Compensation Information Services group at 512-440-3789.

Texas Labor Code Section 409.003 and 409.004, and Rule 122.2 require an employee, or a person on the employee's behalf, to file an Employee's Notice of Injury or Occupational Disease and Claim for Compensation (Form TWCC-41 E/S) with the Texas Workers' Compensation Commission not later than one year after the date of injury or one year after the date the employee knew or should have known a disease was work-related.

Adopted this the 8th day of September, 1997

Todd K. Brown, Executive Director

TWCC Staff
Austin Carrier Representatives
Public Information List