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Run: Workers Compensation First Report of Injury

Workers Compensation First Report of Injury template for documenting the employee, incident, injury, treatment, witnesses, and lost time details needed to st...

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Employee Information

Employee Name (required)

Employee ID

Department (required)

Job Title (required)

Supervisor Name

Incident Details

Date of Injury (required)

Time of Injury (required)

Location of Incident (required)

Type of Incident (required)

Describe What Happened (required)

Injury and Treatment

Body Part Affected (required)

Nature of Injury

Was first aid provided? (required)

Treatment Received

Medical Provider / Facility

Witnesses and Reporting

Were there any witnesses? (required)

Witness Details

Was the supervisor notified? (required)

Date Notified

Time Notified

Lost Time and Work Restrictions

Did the employee miss work? (required)

Lost Time Start Date

Expected Return to Work Date

Work Restrictions / Light Duty Notes

Reporter Certification

Reporter Name (required)

Reporter Title (required)

Reporter Phone

Reporter Email

Certification (required)

Yes No N/A

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Email (required)

Your name (optional)

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