This First Report of Injury template helps employers document workplace incidents for workers compensation and safety compliance. Capture employer and carrier information, employee demographics, wages, job and hire date, accident date and location, activity at time of injury, description of how the incident occurred, affected body parts, and harmful objects. Record medical provider details, treatment location, emergency room and hospitalization status, and dates last worked or death if applicable. Includes fields for report preparer and signature to complete the incident record.
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