Get Incident Investigation/first Report Of Injury - Caps Payroll

The Incident Investigation/First Report of Injury form is an essential document that helps ensure proper reporting of workplace injuries. This guide will walk you through the process of completing the form online, providing clear instructions on each section and its components.

Follow the steps to successfully complete the online form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Provide the injured worker information by entering their name, social security number, address, city, state, zip code, phone number, date of birth, email address, and marital status.
3. Record the details of the incident such as the date and time of the injury, the date and time reported by the employee, the name of the person to whom the injury was reported, and if applicable, the reason for reporting more than 24 hours after the injury.
4. Fill in the occupation, date hired, state of hire, client company details, job/project name, and contact information of the assistant director or supervisor.
5. In the medical provider information section, enter the name and address of the treating clinic or hospital, whether an ambulance was called, and if the employee requires additional treatment or is missing time from work.
6. Describe the accident location, including the exact address, weather conditions, and witness information—names and phone numbers.
7. Detail the injury investigation, including a description of how the injury/illness occurred, the nature of the injury/illness, the parts of the body affected, and list any direct causes of the incident.
8. Indicate if surveillance or video is available, if photos of the accident location or related equipment are available, and provide your name, title, phone, signature, and date.
9. Complete the voluntary statement section, entering the name, phone number, relationship to the injured employee, and a description of the incident. Have the individual sign and date this statement.
10. Once all sections are completed, save any changes, download the document, print it, or share it as necessary.

Complete your forms online today to ensure timely and accurate reporting!