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Run: Workers' Comp First Report of Injury

Workers' Comp First Report of Injury template for capturing the facts needed to file a state FROI on time. Use it to document the incident, treatment, and re...

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Report Overview

Report Type (required)

Is this being submitted within the required state reporting window? (required)

Date of Incident (required)

Use the actual date the injury or illness occurred, not the date it was reported.

Time of Incident

State for Filing (required)

Select the state whose workers' compensation rules apply to this report.

Injured Worker

Worker Full Name (required)

Employee ID

Use internal employee ID if available; do not enter SSN unless explicitly required by your state filing process.

Job Title (required)

Department

Worker Phone Number

Worker Email

Incident Details

Incident Location (required)

Include site, building, department, or jobsite location.

Incident Address

Use if the incident occurred offsite or at a customer location.

What happened? (required)

Provide a factual description of the event, including task being performed and immediate circumstances.

Type of Injury or Illness (required)

Body Part Affected (required)

Was the incident work-related? (required)

Medical Treatment

Was medical treatment received? (required)

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? (required)

Witness Details

Reported By (required)

Reporter Role (required)

Report Date (required)

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Email (required)

Your name (optional)

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