Get the free REPORT OF INJURY - FirstComp

MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS DIVISION OF WORKERS COMPENSATION P.O. BOX 58 JEFFERSON CITY, MO 65102-0058 REPORT OF INJURY (To complete form, see attached instructions) EMPLOYER

How to fill out report of injury

How to fill out a report of injury:

1. Begin by gathering all relevant information about the injured person, including their full name, contact information, and job title. Also, note the date and time of the incident.
2. Describe the details of the injury in a clear and concise manner. Include the location where it occurred, what activities were being performed at the time, and any contributing factors or equipment involved.
3. Provide a narrative of how the injury occurred, focusing on the sequence of events leading up to the incident. Be as specific as possible, avoiding assumptions or speculation.
4. Document any witnesses present during the incident. Record their contact information and ask them to provide a statement describing what they saw or heard. This information can be valuable when investigating the cause of the injury.
5. If any immediate medical attention was given, describe the first aid administered or any medical professionals involved. Include their contact information and any recommendations or instructions given for further treatment.
6. Outline the consequences or impact of the injury on the injured person, such as the severity of the injury, any time off work required, or ongoing medical treatment needed.
7. Include any relevant supporting documents, such as photographs of the scene or equipment involved, medical records, or incident reports from any relevant authorities or organizations.
8. Complete the report by providing your own information as the person filling out the form. Include your name, job title, contact information, and any additional comments or recommendations for preventing similar incidents in the future.

Who needs a report of injury?

1. Employers: Employers need a report of injury to properly document and address workplace accidents or incidents. It helps them in conducting investigations, implementing safety measures, and maintaining a record of workplace injuries for regulatory compliance.
2. Employees: Employees who have suffered a work-related injury should report it to their employer to ensure they receive the necessary medical attention, benefits, and potentially qualify for workers' compensation or other forms of assistance.
3. Insurance Providers: Insurance providers may require a copy of the report of injury to assess claims and determine coverage for medical expenses or lost wages.
4. Regulatory Bodies: In certain industries or regions, regulatory bodies or government agencies may require employers to submit reports of injury for statistical purposes, enforcement of safety regulations, or establishing workplace accident trends.
5. Legal Professionals: If legal proceedings are initiated as a result of the injury, such as personal injury lawsuits or workers' compensation claims, the report of injury will be crucial evidence for establishing liability or entitlement to compensation.

For pdfFiller’s FAQs

What is report of injury?

The report of injury is a document that provides details about an injury that occurred in the workplace.

Who is required to file report of injury?

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

How to fill out report of injury?

The report of injury can be filled out by providing information about the injured employee, the date and location of the injury, the nature of the injury, and any treatment provided.

What is the purpose of report of injury?

The purpose of the report of injury is to document workplace injuries, track trends in injuries, and ensure that proper protocols are followed for worker safety.

What information must be reported on report of injury?

Information such as the injured employee's name, date of birth, job title, date and time of injury, location of injury, description of injury, and any treatment provided must be reported on the report of injury.

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