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Minnesota Department of Labor and Industry Workers Compensation Division PO Box 64221 St. Paul, MN 551640221 (651) 2845030 First Report of Injury See Instructions on Reverse Side PRINT IN INK or TYPE

How to fill out first report of injury

How to Fill Out First Report of Injury:

1. Obtain the necessary form: Contact your employer's human resources department or workers' compensation insurance provider to request the first report of injury form.
2. Provide personal and contact information: Fill in your name, address, phone number, and other relevant personal details as requested on the form.
3. Describe the injury: Clearly explain how the injury occurred, including the date, time, and location. Provide a detailed account of the incident, including any contributing factors or witnesses present.
4. Identify body parts involved: Indicate the specific body parts affected by the injury. Be as specific as possible, describing the affected area or body part in detail.
5. Document injury details: Include information about the severity of the injury, the symptoms experienced, and any immediate actions taken (e.g., first aid administered or medical treatment received).
6. Provide medical treatment information: Record details about the healthcare provider who treated you for the injury, such as their name, address, and phone number. Indicate the date of the initial treatment and any subsequent medical visits related to the injury.
7. Report work-related factors: Describe any work-related factors that may have contributed to the injury. This may include unsafe conditions, equipment malfunctions, or failure to follow proper procedures.
8. Include witness statements: If there were any witnesses to the incident, ask them to provide a written statement about what they saw. Attach these statements to the first report of injury form, if possible.
9. Submit the form: Once you have completed all the necessary information on the form, sign and date it. Keep a copy for your records and submit the original to your employer's designated representative, such as the human resources department or workers' compensation coordinator.

Who Needs First Report of Injury?

1. Employees: Any employee who sustains a work-related injury or illness should complete a first report of injury. This applies to full-time, part-time, temporary, and seasonal workers.
2. Employers: Employers may need the first report of injury to comply with workers' compensation regulations, track workplace injury trends, and initiate the claims process with their workers' compensation insurance provider.
3. Workers' Compensation Insurance Providers: Insurance companies offering workers' compensation coverage require the first report of injury to process claims, evaluate liability, and determine appropriate compensation for the injured employee.
4. Legal Authorities: In some cases, law enforcement or regulatory agencies may request access to first reports of injury to investigate workplace accidents, enforce compliance, or assess potential penalties for violations.

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What is first report of injury?

The first report of injury is a form that must be completed and filed by an employer when an employee is injured on the job.

Who is required to file first report of injury?

Employers are required to file the first report of injury when an employee is injured on the job.

How to fill out first report of injury?

The first report of injury should be filled out completely and accurately, providing details about the injury, the circumstances surrounding it, and the injured employee.

What is the purpose of first report of injury?

The purpose of the first report of injury is to document workplace injuries, provide information for workers' compensation claims, and track injury trends within the company.

What information must be reported on first report of injury?

Information such as the date, time, and location of the injury, the nature of the injury, and the names of any witnesses should be reported on the first report of injury.