Risk Management and Safety: First Report of Injury Form

Name


Address


City State Zip


Work Phone Cell Phone Home Phone


Date of Injury Time of Injury


a/p Hire Date Date of Birth Social Security Number


Date Notified Employer Avg. hours worked/week


Job Title Department


Employment Status: full-time part-time seasonal


Avg. hours worked/day Avg. days worked/week


Wage per hour (if hourly) OR Annual salary (if exempt)


Place of occurrence

Marital status: single married

Gender: male female

Body part affected - be specific (right arm, left foot, etc.)


Injury Details: (include nature of injury (cut, sprain, etc.))





What activity was employee doing at time of injury?


Name of witness to injury Phone:


Supervisor: Phone:



What can be done to prevent recurrence?



Describe nature of treatment (first aid/medical care)



If doctor/medical care, name and address of doctor





* Note: If medical care is required, Risk Management and Safety must be notified within 24 hours of injury.
Risk Management Numbers: 218.299.4242 (office) | 218.299.3682 (Director) | 701.730.8421 (mobile)