Form Injrpt - Report Of Injury - Department Of Workforce Services
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1
2Department of Workforce Services
Division of Workers' Compensation
Report of Injury
EMPLOYER INFORMATION
Claim Number:
Please use BLACK ink. Do not cross zeros or sevens
BUSINESS NAME
WORK COMP EMPLOYER #
ADDRESS
CITY
STATE
ZIP
PHONE
TAX ID TYPE (FEIN OR SSN)
TAX ID NUMBER
NATURE OF BUSINESS (MANUFACTURING, ETC.)
EMPLOYEE INFORMATION
LAST NAME
FIRST NAME
MI
MAILING ADDRESS
CITY
STATE
ZIP
PHYSICAL ADDRESS (IF DIFFERENT FROM MAILING ADDRESS
CITY
STATE
ZIP
PHONE (WITH AREA CODE)
EMAIL ADDRESS
DATE OF BIRTH
DATE OF HIRE
STATE OF HIRE
SOCIAL SECURITY NUMBER
US CITIZEN?
IF NO, PROVIDE INS#
YES
NO
SEX
MARITAL STATUS
FEMALE
MALE
SINGLE
MARRIED
DIVORCED
WIDOWED
INJURY INFORMATION
DATE OF INJURY
TIME OF INJURY
TIME EMPLOYEE BEGAN WORK
TIME EMPLOYEE ENDED WORK
AM
PM
AM
PM
AM
PM
DATE EMPLOYER WAS NOTIFIED OF INJURY
LAST DAY OF WORK AFTER INJURY
DATE OF RETURN TO WORK
EMPLOYEES OCCUPATION (JOB TITLE) WHEN INJURED
TYPE OF EMPLOYEE
EMPLOYEE STATUS
REGULAR
VOLUNTEER
INMATE
OTHER
OWNER
PARTNER
CORPORATE OFFICER
INDEPENDENT CONTRACTOR
NAME OF PERSON CONTACTED
CONTACT PHONE NUMBER
DID INJURY OCCUR ON EMPLOYER PREMISES?
YES
NO
ADDRESS OR LOCATION OF ACCIDENT
CITY
COUNTY
STATE
ZIP
FATALITY
IF YES, WHAT IS THE DATE OF DEATH?
DID INJURY RESULT IN MEDICAL TREATMENT OR LOST TIME FROM WORK?
YES
NO
MEDICAL TREATMENT
LOST TIME FROM WORK
NAME OF PHYSICIAN OR HEALTH CARE PROFESSIONAL
ADDRESS
DATE OF INITIAL EXAM
CITY
STATE
ZIP CODE
LIST ALL BODY PARTS AND LOCATION OF INJURY
(LOCATION BEING THE FOLLOWING: RIGHT, LEFT, BI-LATERAL, MIDDLE, LOWER, UPPER OR UNKNOWN)
PRIMARY BODY PART:
LOCATION:
HAS THIS BODY PART BEEN PREVIOUSLY INJURED?
IF YES, PLEASE EXPLAIN
YES
NO
WAS PRIOR INJURY WORKERS COMP?
WHAT STATE DID THE PRIOR INJURY OCCUR?
DATE PRIOR INJURY OCCURRED?
YES
NO
SECONDARY BODY PART:
LOCATION:
HAS THIS BODY PART BEEN PREVIOUSLY INJURED?
IF YES, PLEASE EXPLAIN
YES
NO
WAS PRIOR INJURY WORKERS COMP?
WHAT STATE DID THE PRIOR INJURY OCCUR?
DATE PRIOR INJURY OCCURRED?
YES
NO
LIST ADDITIONAL BODY PARTS AND LOCATIONS BELOW:
BODY PART:
LOCATION:
BODY PART:
LOCATION:
BODY PART:
LOCATION:
INJRPT
IMPORTANT: PLEASE COMPLETE THE BACKSIDE OF THIS FORM
Revised 11/11
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