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First Report of Injury (DWC-01) An employer must report work-related injuries to his workers compensation insurer and to The Department of Labor and Training, Division of Workers Compensation (DWC).

How to fill out first report of injury

How to fill out the first report of injury:

1. Contact information: Start by providing your contact information, including your full name, address, phone number, and email address.
2. Employee details: Include the employee's personal information, such as their full name, job title, department, and hire date. It's important to accurately identify the injured employee to avoid any confusion.
3. Date and time of injury: Record the exact date and time when the injury occurred. Be as specific as possible to ensure accuracy.
4. Location of the incident: Specify the exact location where the injury occurred, whether it's within the workplace premises or at a specific work site.
5. Description of the injury: Provide a detailed description of the injury sustained by the employee. Include information about the body part affected, the severity of the injury, and any specific circumstances surrounding the incident.
6. Witnesses: If there were any witnesses to the injury, make sure to list their names and contact information. Their testimonies may be valuable during the investigation process.
7. Supervisor's information: Include the details of the employee's supervisor or manager, such as their name, job title, and contact information. This is crucial for proper documentation and communication.
8. Medical treatment: Specify whether the injured employee sought medical treatment, and if so, provide the name and contact information of the healthcare provider or facility.
9. Nature of the injury: Describe the type of injury sustained by the employee, whether it's a sprain, fracture, laceration, or any other specific injury category. Accurately documenting the nature of the injury helps in assessing the severity and potential implications.
10. Statement of the injured employee: If possible, include a statement from the injured employee, detailing their perspective of the incident. This can provide additional insights and contribute to a comprehensive report.

Who needs the first report of injury:

1. Employer: The first report of injury is required by the employer to document and report any workplace injuries to the appropriate authorities. It helps fulfill legal requirements and ensures proper handling of the situation.
2. Insurance company: The insurance company providing workers' compensation coverage needs the first report of injury to assess the claim, determine the coverage, and process any potential benefits for the injured employee.
3. Employee: The injured employee themselves may also need a copy of the first report of injury for personal records, to keep track of medical treatment, or for future reference if necessary. It serves as documentation of the incident and the initial reporting process.

For pdfFiller’s FAQs

What is first report of injury?

The first report of injury is a document that details an employee's work-related injury or illness.

Who is required to file first report of injury?

Employers are typically required to file the first report of injury with the relevant state agency or workers' compensation board.

How to fill out first report of injury?

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

What is the purpose of first report of injury?

The purpose of the first report of injury is to document work-related injuries and illnesses, track trends, and ensure that employees receive the appropriate benefits and medical treatment.

What information must be reported on first report of injury?

Information that must be reported on the first report of injury includes details about the employee, the injury or illness, the date and location of the incident, and any witnesses.

How can I send first report of injury for eSignature?

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