Get Mn Dept Of Labor And Industry First Report Of Injury Form

Completing the Mn Dept Of Labor And Industry First Report Of Injury Form online is an essential process for documenting workplace injuries. This guide provides clear, step-by-step instructions to ensure accurate and efficient completion of the form.

Follow the steps to fill out the form effectively.

1. Click ‘Get Form’ button to access the First Report of Injury Form and open it for editing.
2. Enter the employee's Social Security number in the designated field. This is crucial for the identification of the individual involved in the incident.
3. Fill in the OSHA case number if applicable; this helps in tracking the incident in relation to workplace safety regulations.
4. Input the date of the claimed injury in the MM/DD/YYYY format, ensuring accuracy for record-keeping.
5. Record the time of injury, specifying AM or PM, to provide precise details for the incident.
6. Indicate the time the employee began work on the date of injury, noting whether it was AM or PM.
7. Complete the employee's full name, including last name, first name, and any suffix.
8. Select the gender of the employee from the options provided.
9. Provide the employee's home address, including city, state, and zip code for identification purposes.
10. Record the employee’s marital status, which is important for benefits processing.
11. Document the employee's home phone number for contact purposes.
12. Enter the date of birth of the employee.
13. Fill in the date the employee was hired, which assists in determining eligibility for benefits.
14. Provide the employee's occupation title.
15. Specify the regular department the employee works in.
16. Indicate if the employee is an apprentice.
17. Input the average weekly wage of the employee to assess compensation.
18. Record the hourly rate of pay for the employee.
19. Fill in the normal work schedule by indicating the days of the week the employee typically works.
20. Check all applicable fields for employment status, including full-time, part-time, seasonal, or volunteer work.
21. Describe how the injury or illness occurred, providing detailed context to assist in processing the claim.
22. Specify the nature of the injury or illness, including the body parts affected.
23. Identify all tools, equipment, or substances involved in the incident.
24. Confirm if the injury occurred on the employer’s premises.
25. Document the date of the first day of lost time due to the injury.
26. Indicate whether the employer paid for lost time on the date of injury, providing clarity on compensation.
27. Record the date the employer was notified of the injury, which aids in tracking the reporting process.
28. Fill in the date of first notification of lost time related to the claimed injury.
29. If applicable, document the employee's return to work date.
30. Confirm if the employee returned to the same employer after the injury.
31. Check appropriate options regarding the extent of medical treatment received.
32. Fill in the employer's legal name and DBA if applicable.
33. Document necessary financial identifiers like the FEIN and policy numbers.
34. Finalize by reviewing all entries for accuracy, then save changes, download, print, or share the completed form.

Start filling out the Mn Dept Of Labor And Industry First Report Of Injury Form online today to ensure timely processing of your claim.