Report Of Injury Instructions Form - State Of Wyoming Department Of Employment Workers' Safety And Compensation Division Page 2
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3INJURY INFORMATION
1. Enter the date the employee was injured.
2. Enter the specific time the employee was
injured.
2.
3. Enter the date the employer was notified
1.
3.
of the injury.
4. Enter the job title of the Employee.
5. Enter a detailed written description of the
4.
work activity that caused the accident.
6. Enter a list of all witnesses to the injury.
Please provide a phone number where
5.
the witness can be reached.
7. Enter “Yes” or “No”. If the body part has
been injured before enter the date of the
previous injury and the name and contact
information of the physician or clinic that
6.
treated you.
8. Enter the name of the physician or clinic
7.
you first went for treatment after this
8.
incident. If you did not seek immediate
medical care for this injury state “None”
Attach a separate sheet of paper if
necessary to complete the information
requested in this section.
INJURY CODES
Refer to separate code tables.
EMPLOYEE CERTIFICATION
The employee must sign the injury
report.
The employee’s signature is a release of
information for medical records.
If the employee is not able to sign the report
due to the nature of his injury, an employee
representative may sign.
EMPLOYER CERTIFICATION
Review “Employer Information” on first
page
Answer questions in this section.
If the yes/no section is not marked the
assumed response is that the injury is work
related.
If you mark “no” on the employer
certification explain your objections in a
separate letter.
If your company completes internal
incident reports and/or investigations,
please share the information with the
Division
Revised 04/06
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