Workers' Comp First Report of Injury

First Report of Injury (FROI) form for state workers' compensation filing. Captures all data required for state-specific FROI submission within state-mandated timeline (typically 24-72 hours).

Report Overview

• Report Type
• Is this being submitted within the required state reporting window?
• Date of Incident
  Use the actual date the injury or illness occurred, not the date it was reported.
• Time of Incident
• State for Filing
  Select the state whose workers' compensation rules apply to this report.

Injured Worker

• Worker Full Name
• Employee ID
  Use internal employee ID if available; do not enter SSN unless explicitly required by your state filing process.
• Job Title
• Department
• Worker Phone Number
• Worker Email

Incident Details

• Incident Location
  Include site, building, department, or jobsite location.
• Incident Address
  Use if the incident occurred offsite or at a customer location.
• What happened?
  Provide a factual description of the event, including task being performed and immediate circumstances.
• Type of Injury or Illness
• Body Part Affected
• Was the incident work-related?

Medical Treatment

• Was medical treatment received?
• Date of Treatment
• Treatment Provider
• Is restricted duty or accommodation needed?
  If yes, HR may follow up separately to discuss reasonable accommodation or return-to-work options.

Witnesses and Reporter

• Were there witnesses?
• Witness Details
• Reported By
• Reporter Role
• Report Date