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This document is required by the Workers Compensation Act and must be submitted by employers within three days of an injury to a worker. It details information about the employer, the worker, the

How to fill out employers report of injury

How to fill out EMPLOYER’S REPORT OF INJURY OR OCCUPATIONAL DISEASE

1. Obtain the EMPLOYER’S REPORT OF INJURY OR OCCUPATIONAL DISEASE form from your workplace or the relevant government agency.
2. Fill in the employee's personal information, including their name, address, and date of birth.
3. Provide the details of the incident, including the date, time, and location of the injury or occupational disease.
4. Describe the nature of the injury or disease, including symptoms and severity.
5. Record the names and contact information of any witnesses to the incident.
6. Provide details on how the injury occurred, including any equipment involved and safety measures in place.
7. Indicate whether the employee has received medical treatment and if so, provide the name and contact information of the healthcare provider.
8. Sign and date the report, and ensure all information is accurate and complete.
9. Submit the completed report to the appropriate department or authority as required by law.

Who needs EMPLOYER’S REPORT OF INJURY OR OCCUPATIONAL DISEASE?

1. Employers who have employees that incur workplace injuries or occupational diseases.
2. Workers' compensation agencies that require documentation for claims processing.
3. Insurance companies needing reports for claims related to workplace injuries.

People Also Ask about

How to inform employer of injury?

After the injury, go directly to your supervisor or boss and tell them exactly what happened. You can tell your boss in person, if you are in the same location, or over the phone if you're in a different location. You'll want to tell them the order of events and the names of anyone who saw the injury occur.

What date range must a company post the summary of injuries?

An Injury Report is a formal document used to record details about an individual's injury, accident, or incident. It serves as a critical tool for documenting workplace injuries, facilitating timely reporting, initiating investigations, and ensuring compliance with legal and regulatory requirements.

What is a workplace injury summary report?

Any work-related injury or illness requiring medical treatment beyond first aid. Any work-related diagnosed case of cancer, chronic irreversible diseases, fractured or ed bones or teeth, and punctured eardrums.

What must be true for an employer to record an injury or illness?

A Workplace Injury and Summary Report (WISR) shows your company's cumulative injury and illness experience and allows you to track injury frequency and costs online. You can download a customized WISR instantly and use it to pre-qualify or bid on contracts.

For pdfFiller’s FAQs

What is EMPLOYER’S REPORT OF INJURY OR OCCUPATIONAL DISEASE?

The EMPLOYER’S REPORT OF INJURY OR OCCUPATIONAL DISEASE is a formal document that employers are required to complete when an employee suffers a work-related injury or a disease arising from their occupational environment.

Who is required to file EMPLOYER’S REPORT OF INJURY OR OCCUPATIONAL DISEASE?

Employers who have employees covered by workers' compensation laws are required to file the EMPLOYER’S REPORT OF INJURY OR OCCUPATIONAL DISEASE following any reportable injury or occupational disease incident.

How to fill out EMPLOYER’S REPORT OF INJURY OR OCCUPATIONAL DISEASE?

To fill out the EMPLOYER’S REPORT OF INJURY OR OCCUPATIONAL DISEASE, employers should provide details about the incident, including the employee's information, the nature of the injury or disease, the circumstances surrounding the event, and any medical treatment provided.

What is the purpose of EMPLOYER’S REPORT OF INJURY OR OCCUPATIONAL DISEASE?

The purpose of the EMPLOYER’S REPORT OF INJURY OR OCCUPATIONAL DISEASE is to document the incident for legal and insurance purposes, ensure compliance with safety regulations, and facilitate the employee's access to necessary medical care and workers' compensation benefits.

What information must be reported on EMPLOYER’S REPORT OF INJURY OR OCCUPATIONAL DISEASE?

Information that must be reported includes employee details (name, job title), date and time of injury or disease onset, location of the incident, description of the injury or disease, any witnesses, and details of medical treatment provided.