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First report of injury form 2026
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- Click ‘Get Form’ to open the first report of injury form in the editor.
- Begin by filling out the 'Injured Person Identification' section. Enter the name, last four digits of SSN, date of hire, gender, and job title. Ensure all details are accurate for proper identification.
- In the 'Injury or Illness Description' section, provide the incident date and time. Specify the location and describe the injured body part(s) along with the type of injury. Check all applicable boxes to ensure clarity.
- Detail the incident in the 'Incident Description' section. Answer questions about what you were doing at the time, how it happened, and any contributing factors that led to the incident.
- If applicable, complete the 'Statement Signature' section. Sign and date to confirm that all information is true to your knowledge.
- If refusing treatment, fill out Section 5 carefully, ensuring you meet all criteria before signing.
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See more first report of injury form versions
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| Versions | Form popularity | Fillable & printable |
|---|---|---|
| 2009 | 4.9 Satisfied (30 Votes) |
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Related links
The employer is required to file an Employers First Report of Injury or Illness. [DWC FORM-001 Rev. 10/05] with the injured workers insurance carrier,Read more
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If required by payer to report, enter the first date the patient had the same or a similar illness. Enter the date in the 6-digit format (MM | DD |Read more