- First Report of Injury or Illness (PDF)
First Report of Injury or Illness Instructions (PDF)
This form must be completed once that we, as an employer, become aware of any workplace injury. This must be done, regardless of whether or not the injury is considered serious or if the accident occurred within the course and scope of duties. Please note the following additional items regarding this form:
- The first report must be completed by the supervisor or WCI designee; the form may not be completed by the employee.
- All information must be completed on the form; please use the instructions above to ensure the information is complete and accurate. Incomplete forms will delay the processing of a WCI claim, which in turn may become a violation of state law.
- A separate handout, entitled “Notice of Injured Employee Rights and Responsibilities” (PDF), must be provided to each employee who suffers a workplace injury.
- Witness Statement (PDF)
This form should be filled out by a willing witness who personally witnessed a work-related injury. It may be submitted with the first report, if possible, or in a timely manner after the first report has been submitted.