North Carolina Industrial Commission Form 22 is the Statement of Days Worked and Earnings of Injured Employee. This form contains a table wherein the hours worked and wages earned over the 52 weeks prior to the employee’s injury are recorded. If the employee has worked for fewer than 52 weeks prior to the accident, then you must record the hours worked and wages earned for every week that the employee has worked. If extra allowances such as free rent, lodging or board were paid along with any other wages earned, that value must be included as well.

North Carolina Industrial Commission Form 22 must be completed by the employer, as required by the provisions of the Worker’s Compensation Act, in any case resulting in the death of an employee. This form must also be completed in any case where the wages of the injured employee are disputed.  Any employer attempting to falsify this form in order to deny worker’s compensation benefits may face criminal or civil penalties.Practically speaking, an injured worker may request a Form 22 from the employer/insurance company to help determine what the average weekly wage is. An employee who was injured and believes the insurance company is not correctly compensating them can request the Form 22 to help accurately determine the average weekly wage. If you believe you are not being properly compensated then it is also probably a good idea to talk with an experienced workers’ compensation attorney.