Workers Compensation First Report of Injury

A workplace injury reporting form for documenting employee injury details, treatment, witnesses, and lost time for workers compensation claims.

Employee Information

• Employee Name
• Employee ID
• Department
• Job Title
• Supervisor Name

Incident Details

• Date of Injury
• Time of Injury
• Location of Incident
• Type of Incident
• Describe What Happened

Injury and Treatment

• Body Part Affected
• Nature of Injury
• Was first aid provided?
• Treatment Received
• Medical Provider / Facility

Witnesses and Reporting

• Were there any witnesses?
• Witness Details
• Was the supervisor notified?
• Date Notified
• Time Notified

Lost Time and Work Restrictions

• Did the employee miss work?
• Lost Time Start Date
• Expected Return to Work Date
• Work Restrictions / Light Duty Notes

Reporter Certification

• Reporter Name
• Reporter Title
• Reporter Phone
• Reporter Email
• Certification