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Workers' Compensation First Report of Injury

Workers' Compensation First Report of Injury

Employer: [Employer Name]

Address: [Employer Address], [Employer City], [Employer State] [Employer ZIP]

Phone: [Employer Phone]

Federal EIN: [FEIN]

Industry Code (NAICS): [NAICS Code]

Insurer: [Insurer Name]

Policy Number: [Policy Number]

Report Date: [Report Date]

Prepared By: [Supervisor Name], [Supervisor Title]

SECTION 1 — INJURED EMPLOYEE INFORMATION

Employee Name: [Employee Name]

Home Address: [Employee Address]

Date of Birth: [Employee DOB]

Phone Number: [Employee Phone]

Job Title / Occupation: [Job Title]

Department: [Department]

Date of Hire: [Hire Date]

Employment Type: [Employment Type]

Average Weekly Wage: [Average Weekly Wage]

SECTION 2 — INJURY / ILLNESS DETAILS

Date of Injury: [Injury Date]

Time of Injury: [Injury Time]

Date Reported to Employer: [Date Reported to Employer]

Location of Injury: [Injury Location]

State Where Injury Occurred: [Injury State]

Body Part(s) Injured: [Body Part Injured]

Nature of Injury / Illness: [Nature of Injury]

Cause of Injury: [Cause of Injury]

Description of How Injury Occurred:

[Injury Description]

SECTION 3 — MEDICAL TREATMENT

Type of Medical Treatment: [Medical Treatment]

Treating Physician / Facility: [Treating Physician]

Medical Facility Address: [Medical Facility Address]

Expected Days Away from Work: [Expected Days Away]

OSHA Recordable (29 CFR 1904): [OSHA Recordable]

SECTION 4 — WITNESSES

Witnesses: [Witnesses]

SECTION 5 — CERTIFICATIONS AND NOTICES

The undersigned supervisor certifies that the information contained in this First Report of Injury is accurate and complete to the best of their knowledge. This report has been prepared in accordance with applicable state workers' compensation statutes and OSHA recordkeeping requirements under 29 CFR 1904. Providing false or misleading information on this form may constitute fraud and may result in civil or criminal penalties under state law.

The employer is required to provide a copy of this report to the injured employee upon request and to submit it to the state workers' compensation board or insurer within the time period required by the laws of [Injury State]. Filing deadlines vary by state and typically range from 3 to 10 days following notice of injury.

EMPLOYER / SUPERVISOR CERTIFICATION:

Name: [Supervisor Name]

Title: [Supervisor Title]

Date: [Report Date]

INJURED EMPLOYEE ACKNOWLEDGMENT:

Employer / Supervisor

________________

Signature

Injured Employee

________________

Signature

Maintained by Vladislav Sergienko, Founder·Template last modified: ·Report an error

What Is a Workers' Compensation First Report of Injury?

A Workers' Compensation First Report of Injury in the United States organises the details a party must supply for the purpose it serves.

Here is what employers often get wrong: many assume the FROI is only necessary for serious injuries. That is incorrect. Under most state workers' compensation statutes, any work-related injury that causes the employee to miss work, seek medical treatment beyond basic first aid, or require restricted duty must be reported. Some states require the report even for injuries that require only first aid. The safe rule is to file whenever there is any doubt.

The FROI is separate from — but connected to — OSHA recordkeeping obligations under 29 CFR 1904. An OSHA-recordable injury (one involving days away from work, restricted duty, job transfer, medical treatment beyond first aid, or a significant diagnosed condition) must be logged in the OSHA 300 Log. The FROI triggers the workers' comp insurance process, while the OSHA 300 Log is a federal recordkeeping obligation. Many injuries trigger both requirements simultaneously.

The document captures critical details: the employer's identity and insurance information, the injured employee's personal and employment data, the exact circumstances of the injury including date, time, location, and cause, the nature and body part affected, and the medical treatment received. It also documents who witnessed the injury and identifies the supervisor or safety officer certifying the report. This information forms the evidentiary foundation of the workers' compensation claim.

When Do You Need a Workers' Compensation First Report of Injury?

An employer must file a First Report of Injury in several situations, and failing to do so on time carries real consequences — including fines, penalties, and loss of the right to challenge questionable claims.

File immediately whenever an employee is injured at work and requires medical treatment beyond first aid. This includes emergency room visits, urgent care, physician appointments, surgery, or hospitalization. The filing deadline runs from when the employer had actual notice of the injury, not necessarily when the employer decided the injury was serious enough. If an employee tells a supervisor they hurt their back lifting boxes on a Tuesday, the clock starts Tuesday — not when the supervisor gets around to investigating.

File when an injury results in any days away from work. Even a single missed day triggers the reporting obligation under most state statutes. The same applies to injuries that result in restricted work or job transfer — if the doctor says the worker cannot lift more than 10 pounds and the employer accommodates that with a desk assignment, that restricted-duty arrangement must still be reported.

Occupational illnesses and cumulative trauma conditions also require a FROI. These include hearing loss from prolonged noise exposure, respiratory conditions from chemical inhalation, repetitive stress injuries like carpal tunnel syndrome, and occupational diseases like asbestosis or silicosis. The reporting date for these conditions is typically the date the worker knew or should have known the condition was work-related.

Many employers also complete a FROI for near-miss events with potential for injury, even where no actual injury occurred, as part of a proactive safety culture — though this is a best practice rather than a legal requirement in most states.

What to Include in Your Workers' Compensation First Report of Injury

A properly completed First Report of Injury protects the employer, ensures the injured worker receives timely benefits, and satisfies state and federal reporting obligations. Here are the elements that matter most.

Employer identification is the starting point. This includes the full legal name of the business, the FEIN, the physical address of the workplace, and the workers' compensation policy number with the insurer's name. Errors here cause delays in claim processing because the insurer cannot match the report to the correct policy.

Employee information must be precise. Full legal name, home address, date of birth, hire date, job title, employment classification (full-time, part-time, seasonal, temporary), and average weekly wage are all required. The average weekly wage is particularly important because it directly determines the benefit rate — typically two-thirds of AWW up to the state maximum. Underreporting wages reduces benefits owed to the worker; overstating wages inflates insurance costs.

Injury description is the most critical narrative section. It must explain exactly what the employee was doing, what went wrong, how the injury happened, and what body part was affected. Vague descriptions like 'back injury while working' are insufficient. A complete description reads more like: 'Employee was lifting a 75-lb bag of concrete mix from a pallet onto a conveyor belt at approximately 9:30 AM in Warehouse C when they felt a sudden sharp pain in their lower back. No equipment malfunction was involved. Employee had completed two prior lifts of the same weight without incident.'

Medical treatment documentation identifies the treating physician or facility, the type of care received, and any expected time away from work. This data feeds directly into the insurer's claim reserve calculations and determines whether the injury triggers OSHA recordability under 29 CFR 1904.

Finally, timely submission is itself a key element. State deadlines range from 3 days (Florida, Texas) to 10 days (New York, California) from the date the employer learned of the injury. Missing these deadlines can result in civil penalties ranging from a few hundred to several thousand dollars per violation.

Sources & Citations

Statutory citations link to official government sources.

  1. 29 CFR 1904US – eCFR

Cite this page

Reference this free template in an article, syllabus, or research note:

APA

Forms Legal. (2026). Workers' Compensation First Report of Injury (United States) [Legal document template]. Forms Legal. https://forms-legal.com/usa/employment/forms/workers-comp-first-report

MLA

"Workers' Compensation First Report of Injury (United States)." Forms Legal, 2026, https://forms-legal.com/usa/employment/forms/workers-comp-first-report.

BibTeX
@misc{formslegal-workers-comp-first-report,
  author       = {{Forms Legal}},
  title        = {Workers' Compensation First Report of Injury (United States)},
  year         = {2026},
  howpublished = {\url{https://forms-legal.com/usa/employment/forms/workers-comp-first-report}},
  note         = {Free legal document template. Based on Fair Labor Standards Act (29 U.S.C. §201-219)}
}

Frequently Asked Questions

Based on Fair Labor Standards Act (29 U.S.C. §201-219) — Template last modified June 2026Verify the source →

This template is provided for informational purposes only and does not constitute legal advice. Laws vary by jurisdiction and change over time. Consult a qualified attorney for advice specific to your situation.Full disclaimer

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