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Minnesota Department of Labor and Industry Workers' Compensation Division PO Box 64221 St. Paul, MN 55164-0221 (651) 284-5030 Reset First Report of Injury See Instructions on Reverse Side PRINT IN

How to fill out first report of injury

How to fill out first report of injury:

1. Gather the necessary information: Start by collecting all the relevant details about the injured person, such as their name, date of birth, and contact information. You will also need to know the date, time, and location of the incident, as well as any witnesses or parties involved.
2. Describe the incident: Provide a clear and concise account of what happened, including the cause of the injury and any contributing factors. Be specific and provide as much detail as possible to accurately capture the circumstances surrounding the incident.
3. Document the injuries: Describe the nature and extent of the injuries sustained by the individual. List any visible wounds, fractures, or internal injuries, and include information about whether immediate medical attention was required.
4. Include medical treatment information: If the injured person received medical treatment, provide details about the healthcare facility where they were treated, the name of the attending physician, and any prescribed medication or ongoing treatment plans.
5. Report the incident to the appropriate parties: Depending on the guidelines set by your organization or jurisdiction, you may need to submit the first report of injury to various entities, such as the employer, insurance company, or regulatory authorities. Ensure that you follow the designated reporting procedures and provide accurate copies of the report to the relevant recipients.

Who needs first report of injury:

1. Employers: Employers typically require a first report of injury to initiate the process of workers' compensation claims. This report helps them document the incident properly and ensures that necessary actions are taken to provide appropriate support and compensation to the injured employee.
2. Insurance companies: Insurance companies involved in workers' compensation or liability coverage policies may require a copy of the first report of injury to assess the claim and determine the appropriate coverage and benefits.
3. Regulatory authorities: Depending on the jurisdiction, regulatory authorities, such as state labor departments or occupational safety agencies, may require a first report of injury to track workplace incidents, enforce compliance with safety regulations, and conduct investigations if necessary.

Remember to consult with the specific guidelines and requirements established by your employer and local laws to ensure accurate and timely completion of the first report of injury.

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What is first report of injury?

The first report of injury is a document that must be filed by the employer or the injured employee when an employee sustains a work-related injury or illness.

Who is required to file first report of injury?

The employer is generally responsible for filing the first report of injury, but in some cases, the injured employee may be required to file it.

How to fill out first report of injury?

The first report of injury typically includes details about the injured employee, the nature and cause of the injury, the date and time of the incident, medical treatment received, and other relevant information. It is usually filled out using a specific form provided by the relevant workers' compensation agency.

What is the purpose of first report of injury?

The purpose of the first report of injury is to document the occurrence of a work-related injury or illness, initiate the workers' compensation claim process, and provide important information about the incident for record-keeping and statistical purposes.

What information must be reported on first report of injury?

The first report of injury typically requires information such as the employee's name, contact details, job title, date of birth, Social Security number, details of the injury or illness, date and time of the incident, details of medical treatment received, and other relevant information as required by the specific workers' compensation agency.