Employer'S First Report And Employee'S Notice Of Injury Or Occupational Illness Template
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1EMPLOYER’S FIRST REPORT AND EMPLOYEE’S NOTICE OF INJURY
OR OCCUPATIONAL ILLNESS
VI DEPARTMENT OF LABOR, DIVISION OF WORKER’S COMPENSATION
CASE NUMBER
ST. THOMAS AND ST. CROIX
(NOT TO BE FILLED BY EMPLOYER)
1. Employer
2. OSHA Case or File Number
(Company Name)
3. Mail Address
4. V.I.E.S.A. Account Number
(No., Street, City, Zip)
5. Employer’s Location if Different From Mailing Address
6. Insurance Policy Number
7. Nature of Business, Products Manufactured
8. Number of Employees
(Construction, Trade, Etc.)
9. Employee’s Name
10. Social Security Number
11. Age
D.O.B.
12. Sex
(First, Middle, Last)
13. Employee’s Mailing Address
14. How Long Employed?
15. Nationality?
(No., Street, City or P.O. Box, Zip)
16. Occupation
17. Department in which Employed
18. Name of Supervisor
19. Hours Worked Per Week
20. Days Per Week
21. Wage Per Hour
22. Salary per Wk/Mo.
23. If other Advantages Are Provided,
Estimate Value Per Wk/Mo.
(Specify)
24. Place of Accident or Exposure
25. State if Employer’s Premises
26. Department
(Address and Location)
27. Date of Injury
28. Day of Week
29. Time of Day ______ AM
30. Date Supervisor First Knew of Occurrence
31. Did Employee Die?
______ PM
32. Date Disability Began or Occupational
33. Time of Day ______ AM
34. Was Insured Paid in
35. Time of Day Employee Begins Work
Illness Became Evident
Full This Day?
______ PM
36. Activity of Employee at Time of Accident or Exposure (Be specific: If Using Tools or Equipment or Handling Materials. Name them and
Tell What Employee was doing with them)
37. TYPE OF ACCIDENT that Occurred (Describe Events Fully: Name Objects or Substances Involved and How They Were Involved and How They were
Involved: Give Full Details On All Contributory Factors)
38. Name and Addresses of Witnesses
39. SOURCE OF INJURY or Occupational Illness ( Name Object Struck or Struck By: Vapor, Poison, Chemical; If Strain or Hernia, Name Thing Lifted or
Pushed; If solely From Bodily Motion, Describe Twisting Resulting in Injury; Etc.)
40. NATURE OF INJURY or Occupational Illness and PART OF BODY Affected (E.G., Amputation of Right Index Finger, Lead Poisoning, Inflammation of
Left Eye)
41. Name and Address of Treating Practitioner
42. If Hospitalized, Name and Address of Hospital
43. If Employee Returned to Work,
44. At What Wage?
45. At What Occupation
46. Was Case Recorded on OSHA Long 200S
Give Date and Hour
REPORT PREPARED BY (PRINT OR TYPE NAME)
POSITION
TELEPHONE NUMBER
EMPLOYER’S SIGNATURE
DATE OF EMPLOYER’S SIGNATURE
EMPLOYEE’S SIGNATURE
EMPLOYEE’S TELEPHONE NUMBER
DATE OF EMPLOYEE’S SIGNATURE
FORM NUMBER
VIDSS:1-1-75
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