First Report of Injury

Employee Report of Incident

To be used for reporting Major/Minor Injuries, Fatalities, Near-Misses, and Report Only Incidents
A company makes a significant mistake by punishing or blaming employees for workplace injuries.

• We want to learn the details of how and why the incident happened.
• What could we have done better, what could you have done better?
• We want to learn and feed this back into training and prevention of future injuries.

Thank you for providing this information.

Step 2 of 8

We need this information for state compliance forms and accident investigation. It also helps to inform future safety improvements.
Step 2 of 6

The information here is for your reference.
Section 2 - Employee Information
Organization ID*
Employer's Incident Report Number*
Employee's Name*
Incident Location Name*
Incident Type*
Home Address*

Street Address

Street Address Line 2

CityState

Zip Code
Birth Date*

MonthDayYear
Date
Are you:*

Right handedLeft handedAmbidextrous (use of both hands)

Step 3 of 8

We need to get your side of the story to complete an investigation and properly pay your claim.
Step 3 of 6

We need this information to complete an investigation and help prevent future incidents.
Section 3 - Employee Statement
Date of Incident*
Describe in your own words how the incident occurred: *
Tell us how the incident occurred. Examples: “When ladder slipped on wet floor, I fell 20 feet”; “I was sprayed with chlorine when gasket broke during replacement”; “I developed soreness in my wrist over time."
Do you have a job at another company?*

YesNo
Please provide details on your other job(s):*
Have you received prior medical treatment for this injury?*

YesNo
Initial prior medical treatment date (approximate if needed)*

MonthDayYear
Date
Describe details of prior medical care received:*
BY SIGNING BELOW, I CERTIFY THAT THE ABOVE STATEMENTS ARE TRUE AND CORRECT.
Signature*

Clear

Step 5 of 8

We need this information for a more detailed accident investigation which helps to pay your claim properly.
Step 5 of 6

(step 6 is just the signature page)

We need this information for a more detailed investigation to help prevent future incidents.
Section 5 - Injury Information

Incident Details
What job/activity were you doing at the time of the incident?*
What specific equipment were you working on, if any?*
What could you have done to prevent the incident from occuring?*

Step 7 of 8

(step 8 is just the signature page)

We need photos and video for documentation to properly pay your claim and prevent future accidents.
Section 7 - Document the Scene

Proper documentation is key to getting your claim paid properly and preventing future incidents.
Photo 1: Take distance shots and close shots, take photos at different angles, include an item of known dimension for scale.
Photo 2: Take distance shots and close shots, take photos at different angles, include an item of known dimension for scale.
Photo 3: Take distance shots and close shots, take photos at different angles, include an item of known dimension for scale.
Photo 4: Take distance shots and close shots, take photos at different angles, include an item of known dimension for scale.
Photo 5: Take distance shots and close shots, take photos at different angles, include an item of known dimension for scale.
Record a Video of the Scene: Narrate what is being filmed, describe objects, size, direction, location, etc.; slowly scan 360 degrees to establish the location
Thank you for providing these valuable photos and video!

Step 8 of 8

(thank you for taking the time to document your injury)
Step 6 of 6

(thank you for taking the time to document your near-miss incident)
Section 7 - Rights & Responsibilities
PANEL PHYSICIAN LIST AND INFORMATION

This section includes information on where you can seek treatment for your work injury. Risk and Safety can help you set up treatment with one of the providers below.

Please take a moment to read and understand the following information. You acknowledge that you have received this information and will attest to the fact that you have read and understood it in a later section.
EMPLOYEE RIGHTS AND RESPONSIBILITIES

This section includes important information regarding your rights and responsibilities under the PA Workers Compensation Act. Please take a moment to read and understand the following information.

You acknowledge that you have received this information and will attest to the fact that you have read and understood it in a later section.
EMPLOYEE DECLINATION OF MEDICAL TREATMENT SECTION

I understand that I am entitled to examination and/or treatment under the company accident/injury/incident procedures. I reported an accident/injury/incident involving the company as of today. I have supplied information about my injury above.

I understand that this declination is a voluntary decision and does not waive my rights for future medical treatment. I agree to notify the company if, in the future, I feel medical treatment for this injury becomes necessary and will want to seek medical treatment.
Employee Declination of Medical Treatment*

I have been provided an opportunity to receive medical treatment for a reported injury but do not feel it is necessary at this time. I am declining the offer for medical treatment made by the companyI am not injured and do not need medical treatment.I'm injured and seeking medical treatment. This declination does not apply to me
ACKNOWLEDGEMENT SECTION

We have provided you with important information concerning your rights and responsibilities after an injury, including information on where you can receive treatment. Even if you aren't injured, its important information for you to know and understand. This information is also posted at every base location and can be obtained from Risk and Safety.

Our company will do everything we can to help and support injured workers. However, sometimes people see that as an opportunity to take advantage.

Do you understand that Workers' Compensation fraud is a serious crime? Insurance fraud is a felony and is punishable by a fine up to $50,000 or double the value of the fraud, and/or imprisonment of not more than 7 years along with civil penalties. Anyone who commits fraud may be subject to civil or criminal penalties.

The company actively investigates all claims of injury and refers any suspicious activity or potentially fraudulent injury claims to the Office of Attorney General for criminal investigation and prosecution.
I understand and attest that my injury claim is truthful and correct

Yes
AUTHORIZATION TO FURNISH MEDICAL INFORMATION

Do you authorize your treatment provider to furnish the company, its claims administrator, and insurance provider with copies of your work-related medical records and reports including information relative to diagnosis, treatment, and prognosis for my condition? This information is needed to determine the extent of injury, return to work ability, and to assist in furnishing payment for services.

Documentation from providers shall include (where pertinent) the claimant’s history, diagnosis, description of treatment and services rendered, physical findings, and prognosis, including whether or not there has been recovery enabling the claimant to return to work with or without limitations, and specific restrictions, if any, regarding return to work. Bills for follow-up visits should include progress/office notes to support the diagnosis and codes billed.

I understand that I have the right to revoke this authorization, in writing and at any time, except where uses or disclosures have already been made based upon my original permission. I might not be able to revoke this authorization if its purpose was to obtain insurance. I understand that uses and disclosures already made based upon my original permission cannot be taken back.
I consent to the release of my protected health information for the purposes stated above

Yes
AFFIRMATION OF WORKERS' COMPENSATION INFORMATION

Do you affirm that you have received, read, and understand the workers' compensation information provided to you, including the information in the documents (pictures) above?
I affirm I have received, read, and understand the workers' compensation information provided to me.

Yes
CERTIFICATE OF ACCURACY
Writing your name and e-signature indicates that you have received, read, and understand the workers compensation information provided to you, including the information in the documents (pictures) above.
Employee Full Name - Certificate of Accuracy*
Date - Certificate of Accuracy*

MonthDayYear
Date
Employee Signature - Certificate of Accuracy*
Injured Form Submitted*
Should be Empty:

Employee Report of Incident

Section 2 - Employee Information

Section 3 - Employee Statement

Section 4 - Why Did the Incident Happen?

Safety Equipment

Section 5 - Injury Information

Section 6 - What Body Part(s) Were Injured?

Section 7 - Document the Scene

Section 7 - Rights & Responsibilities