Get Employers First Report Of Injury Or Illness Nm Form

Filling out the Employers First Report Of Injury Or Illness Nm Form is a crucial step in documenting workplace injuries and ensuring that employees receive the necessary support. This guide provides clear, step-by-step instructions to assist users in completing the form accurately and efficiently.

Follow the steps to successfully complete the form online.

1. Click ‘Get Form’ button to access the Employers First Report Of Injury Or Illness Nm Form and open it in the editor.
2. Fill in the employee's social security number in the designated field. Do not use the space provided for any other information.
3. Enter the OSHA case number, if applicable, in the specified section.
4. Record the date of the claimed injury in MM/DD/YYYY format along with the exact time of the injury.
5. Indicate the time the employee began work on the date of injury, specifying AM or PM.
6. Provide the employee's full name, including their last name, first name, and middle initial.
7. Check the appropriate box to indicate the employee's gender.
8. Select the marital status of the employee from the provided options.
9. Input the employee's home address, ensuring to include the city, state, and zip code.
10. Enter the employee's home phone number for contact purposes.
11. Fill in the employee's date of birth.
12. Indicate the employee's occupation.
13. Provide the name of the regular department where the employee works.
14. Enter the date the employee was hired.
15. Record the employee's average weekly wage.
16. Fill in the rate per hour the employee is paid.
17. Specify the hours the employee works per day and whether they are part-time or full-time.
18. Indicate the number of days the employee works per week.
19. If applicable, mention whether the employee is an apprentice.
20. Provide a detailed account of how the injury occurred, including what the employee was doing before the incident.
21. Describe the injury or illness, specifying the affected body parts.
22. List any tools, equipment, or substances involved in the incident.
23. Indicate whether the injury occurred on the employer's premises.
24. Enter the date of the first day of lost time due to the injury.
25. Check the appropriate box to indicate if the employer paid for lost time on the day of injury.
26. Note the date the employer was notified of the injury and the date of the lost time.
27. Provide the treating physician's information, including name, address, and phone number.
28. Fill in any information regarding emergency room visits and overnight stays, if applicable.
29. Complete the employer's legal name, DBA name (if applicable), mailing address, and federal employment identification number (FEIN).
30. Finalize the form by reviewing all entered information for accuracy and completeness. Save changes, download the form, print it, or share it as necessary.

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