2026 First Report of Injury

2026 First Report of Injury
Injury Reporting Process
1.     In the event of a Medical Emergency, Call 911

2.     For Minor injuries, administer First Aid and determine if additional treatment will be needed

3.     Notify superintendent of incident/injury

4.     Seek treatment based on the Policy for medical service location determination below

5.     Superintendent will provide the First Report of Injury form to the injured employee, safety manager and safety specialist

6.     Superintendent will inform Acoustics Associates Project Manager of incident

7.     Employee fills out First Report of injury along with associated clinic documentation

8.     Employee must send the documentation to safety manager and superintendent within 24 hours of incident
Policy for Medical Service Location Determination
Minor injuries (examples include Cuts, Lacerations, Minor Dislocations, Burns, Scalds, General Pain)

Minnesota Occupational Health nearest to jobsite - Locations and Hours:

Coon Rapids - 600 Coon Rapids Blvd NW, Coon Rapids, MN 55449

(Monday to Friday 7:00 am to 4:00 pm)

Woodbury - 4123 Radio Drive, Woodbury, MN 55125

(Monday, Tuesday, Thursday, Friday 7:30 am to 4:30 pm)

Eagan - 1400 Corporate Center Curve, #200, Eagan, MN 55121

                        (Monday to Friday 7:00 am to 4:00 pm)



Shakopee - 4360 12th Ave E., Shakopee, MN 55379

                        (Monday to Friday 7:00 am to 4:00 pm)



St. Paul/Midway - 1661 St Anthony Ave., 2nd floor, St. Paul, MN 55104

                        (Monday to Friday 7:00 am to 4:00 pm)

*For minor injuries that occur outside of normal clinic hours visit Urgent Care nearest to jobsite

Major injuries (examples include Severe Hemorrhage, Severe Chest Pain, Extensive Burns, Poisoning)

Emergency Room nearest to jobsite
First Report of Injury Form
Date of Claimed Injury*

MonthDayYear
Date
Time of Injury*

Hour Minutes

AM/PM Option
Social Security Number*
Employee Name*

First NameLast Name
Employee Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth*

MonthDayYear
Date
MaleFemale
MarriedDivorced / SeparatedSingle
Job Title / Position*
YesNo
Date Hired*

MonthDayYear
Date
Hourly Rate of Pay*
YesNo
Job Name*
Job Number
Job Site Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Type of injury*
Body Part Injured*
RightLeftBoth
In detail, describe how the injury occurred and what you were doing before the injury*
NoneOnsite MedicalLocal ClinicHospital / Emergency Room
Clinic / Hospital Name
Clinic / Hospital Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
YesNo
Witness Name

First NameLast Name
Witness Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Should be Empty:

2026 First Report of Injury

Injury Reporting Process

Policy for Medical Service Location Determination

First Report of Injury Form