Get the free First Report of Injury Form. Worker injury reporting - purdue

Print Form Click here to go to the First Report of Injury web page for more information and a link to a tutorial about completing and submitting this form. Submit by Email Date of Submission: FIRST

How to fill out first report of injury

How to fill out the first report of injury:

1. Gather necessary information: Start by collecting all the essential details related to the injury, such as the date, time, and location of the incident, the name and contact information of the injured individual, and any witnesses present.
2. Describe the injury: Provide a clear and concise description of the injury. Include specific details about the body part affected, the severity of the injury, and any immediate medical attention sought.
3. Document the cause: Identify and document the cause or circumstances that led to the injury. This may involve identifying hazardous conditions, equipment malfunctions, or any other factors that contributed to the incident.
4. Include witness statements: If there were any witnesses to the injury, include their statements in the report. Ensure their contact information is also provided for further investigation or verification if necessary.
5. Note other contributing factors: If there were any factors that contributed to the injury, such as the employee's actions or non-compliance with safety protocols, be sure to include those in the report as well.
6. Provide medical treatment information: Include details about the medical treatment received by the injured person, such as emergency care, hospitalization, or follow-up medical appointments. This information helps to establish the severity of the injury and its impact on the individual.
7. Obtain supervisor or employer signature: Once the report is completed, ensure it is reviewed and signed by a supervisor or the employer. This confirms their awareness of the incident and allows them to take appropriate actions, such as initiating an investigation or filing insurance claims.

Who needs the first report of injury:

1. Employers: Employers require the first report of injury to maintain accurate records of workplace incidents. It helps them track patterns, analyze potential hazards, and take corrective measures to prevent future occurrences.
2. Insurance companies: Insurance companies require the first report of injury to evaluate and process any workers' compensation claims filed by the injured individual. This allows them to determine coverage eligibility and provide necessary benefits.
3. Legal authorities: In some cases, legal authorities may require the first report of injury to investigate workplace accidents, especially if there are concerns about safety violations or potential negligence. This report can play a vital role in determining liability and taking appropriate legal actions, if necessary.

For pdfFiller’s FAQs

What is first report of injury?

First report of injury is a form or report that documents an employee's injury or illness that occurred during the course of employment.

Who is required to file first report of injury?

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

How to fill out first report of injury?

To fill out the first report of injury, the employer must provide details about the employee's injury, including how it occurred and the extent of the injury.

What is the purpose of first report of injury?

The purpose of the first report of injury is to document workplace injuries and illnesses, facilitate the employee's access to workers' compensation benefits, and help prevent future incidents.

What information must be reported on first report of injury?

The first report of injury typically requires information such as the employee's name, date of injury, description of the injury, medical treatment received, and other relevant details.

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