First Report of Injury or Illness
Workers Compensations
Employee Name
*
First Name
Last Name
Employee Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Employee Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Employee Date of Birth
*
-
Month
-
Day
Year
Date
Occupation
*
Employment Status
*
Please Select
Active
Inactive
Gender
*
Please Select
Female
Male
Social Security Number
*
Date Hired
-
Month
-
Day
Year
Date
Date Injured
*
-
Month
-
Day
Year
Date
Marital Status
*
Please Select
Single
Married
Divorced
Separated
Widowed
Wage Rate
Wage Per
Please Select
Hour
Week
Month
Year
Hours worked per week
Number of days per week.
Full Pay for the day of injury?
Yes
No
Did salary continue?
Yes
No
Place of accident or exposure
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
County
*
Did injury/illness occur on the employer's premises
*
Yes
No
Time injury occurred
*
Hour Minutes
AM
PM
AM/PM Option
Time employee began work
*
Hour Minutes
AM
PM
AM/PM Option
Date last worked
*
-
Month
-
Day
Year
Date
Date employer notified
*
-
Month
-
Day
Year
Date
Date disability began
*
-
Month
-
Day
Year
Date
Date returned to work
-
Month
-
Day
Year
Date
If fatal, date of death
-
Month
-
Day
Year
Date
Injury type (strain, cut, etc)
*
Part of the body affected (Specify left or right side if applicable)
*
Body part injured before?
*
Yes
No
Equipment, material or chemicals employee was using upon occurrence?
*
Injury report to (name)
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
How injury or illness occurred? (Describe the sequence of events. Including objects or substances that directly caused the injury)
*
Was the accident caused by the failure of a machine or product
*
Yes
No
If the accident was caused by any person or business other than the injured worker, co-worker or the employer, please identify
*
Was safety equipment provided?
*
Yes
No
Was safety equipment used
*
Yes
No
Were other workers also injured
*
Yes
No
If so, list other worker's names
Physician or hospital (name and address) - If none contacted enter none
*
Medical Treatment
*
No medical treatment
Minor by employer
Minor - clinic/hospital
Emergency care
Anticipated major/med time loss
Hospitalized overnight
Did anyone witness the accident:
*
Yes
No
If yes, provided name and phone number
Preparer's name and title
*
Preparer's Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Preparer's Email
*
example@example.com
Date Submitted
-
Month
-
Day
Year
Date
Please verify that you are human
*
Submit
Should be Empty: