Get the free Employer's First Report of Injury or Occupational Illness

This form is used to report injuries or occupational illnesses occurring in the workplace to the Office of Workers' Compensation Programs.

How to fill out employers first report of

How to fill out Employer's First Report of Injury or Occupational Illness

1. Begin with the employer's details: Fill in the name, address, and contact information of the employer.
2. Enter employee information: Provide the employee's full name, address, date of birth, and social security number.
3. Describe the incident: Write a detailed account of the injury or illness, including the date, time, and location where it occurred.
4. Specify the nature of the injury or illness: Clearly document the type of injury or illness sustained by the employee.
5. Include details about medical treatment: Indicate whether the employee received medical attention, and if so, provide the name of the medical facility or provider.
6. List any witnesses: Write the names and contact information of any individuals who witnessed the incident.
7. Complete additional employer and incident details: Fill in any other required fields, including the job title of the employee and a description of their work duties at the time of the incident.
8. Sign and date the report: The employer or authorized representative must sign and date the form to certify its accuracy.

Who needs Employer's First Report of Injury or Occupational Illness?

1. Employers need the Employer's First Report of Injury or Occupational Illness to document workplace incidents for their records and for reporting purposes.
2. Employees may need the report to comply with workers' compensation claims and seek medical treatment or benefits.

People Also Ask about

What is an injury report?

Documentation: Injury reports document the date, time, location, nature of injuries, and contributing factors related to workplace accidents or incidents. They provide a detailed account of events, injuries sustained, and the individuals involved, serving as a historical record for reference and analysis.

What is the first report of injury related to?

First Report of Injury/Notice of Contests When a worker is injured or has an occupational disease that results in more than three days/shifts of lost time, permanent impairment, or death, the insurance carrier must file a First Report of Injury (FROI) with the Division of Workers' Compensation (DOWC) within 10 days.

How do I report a work injury in California?

Contact DIR to request an interpreter over the phone: Office NameTopicPhone Numbers Cal/OSHA Workplace Safety and Health 833-579-0927 Labor Commissioner's Office Wages, breaks, retaliation and labor laws 833-526-4636 Division of Workers' Compensation Benefits for work-related injuries and illnesses 1-800-736-74011 more row

What are the steps you follow when a worker is injured?

If your employee has a work-related injury or illness, you should seek medical care for them. Your employee should file a report with the company to start the workers' compensation process. After getting their report, you can start documenting and gathering information about their injury or illness.

What is the employer's report of occupational injury or illness in California?

The Employer's Report of Occupational Injury or Illness (Form 5020). Every employer is required to file a complete report of every occupational injury or illness to each employee which results in lost time beyond the date of injury or illness or which requires medical treatment beyond first aid*.

How long does an employee have to report an injury in California?

Report the injury or illness to your employer If you don't report your injury within 30 days, you could lose your right to receive workers' compensation benefits.

What is the employer's report of occupational injury in California?

The Employer's Report of Occupational Injury or Illness (Form 5020). Every employer is required to file a complete report of every occupational injury or illness to each employee which results in lost time beyond the date of injury or illness or which requires medical treatment beyond first aid*.

What determines occupational illness or injury?

Occupational Safety and Health Administration.

For pdfFiller’s FAQs

What is Employer's First Report of Injury or Occupational Illness?

The Employer's First Report of Injury or Occupational Illness is a form used by employers to document and report workplace injuries or illnesses to insurance carriers and relevant state agencies.

Who is required to file Employer's First Report of Injury or Occupational Illness?

Employers are required to file the Employer's First Report of Injury or Occupational Illness when an employee is injured at work or develops an occupational illness that requires medical attention or results in a loss of work time.

How to fill out Employer's First Report of Injury or Occupational Illness?

To fill out the Employer's First Report of Injury or Occupational Illness, employers should provide accurate and complete information including the employee's details, the nature of the injury or illness, the circumstances of the incident, and any medical treatment administered.

What is the purpose of Employer's First Report of Injury or Occupational Illness?

The purpose of the Employer's First Report of Injury or Occupational Illness is to ensure timely communication of workplace incidents, help secure workers' compensation claims, and facilitate proper record-keeping for safety and legal compliance.

What information must be reported on Employer's First Report of Injury or Occupational Illness?

The information that must be reported includes the employee's name, job title, description of the injury or illness, date and time of the incident, location, any witnesses, and details regarding medical treatment received.