Ct first report injury form 2026

1. Click ‘Get Form’ to open the ct first report injury form in the editor.
2. Begin by entering the Agency Location Code and Division/Region in the designated fields.
3. Input the employee's Social Security Number (SSN) and Employee Number for identification purposes.
4. Fill in the Name of the Injured Worker, including First, Last, and Middle Initial.
5. Complete the Home Address section with City or Town, State, and Zip code.
6. Provide the Home Telephone number and Date of Birth of the injured worker.
7. Indicate the Sex, Job Classification, Date of Hire, Date of Incident, Time of Incident, and Time Employer Notified.
8. Answer whether the Injury was Fatal and provide relevant dates if applicable.
9. Describe how the Injury Occurred and specify the Type of Injury along with Body Part(s) Affected.
10. Confirm if the Injury Occurred on Employer Premises and if Medical Treatment is being sought.
11. List any Witnesses to the Injury along with their contact information.
12. Complete Supervisor information including Name, Title, Work Phone, and Signature for finalization.

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