Get Umd Guidelines For Completing The First Report Of Injury Form For ... - D Umn

This guide provides a clear and supportive walkthrough for completing the UMD Guidelines for the First Report of Injury form for work-related injuries. It is designed to assist users in understanding each section of the form and ensuring accurate submission.

Follow the steps to effectively complete your injury report form.

1. Press the ‘Get Form’ button to access the document and open it in an editor.
2. Fill out the employee's social security number in the designated box at the top of the form.
3. Leave Box 2 blank, as instructed.
4. Enter the date of the claimed injury in Box 3 using the format MM/DD/YYYY.
5. Record the time of injury in Box 4 and include the time the employee began work on that date in Box 5.
6. Provide the employee's full name (last, first, middle) in Box 6.
7. Indicate gender and marital status in Boxes 7 and 8 by selecting the appropriate options.
8. Complete the home address details in Boxes 9 and 10, ensuring all information is typed or printed clearly.
9. In Box 11, enter the employee's date of birth.
10. Fill in the occupation in Box 12.
11. Include the regular department in Box 13 and the employee's date of hire in Box 14.
12. Detail average weekly wage in Box 15, writing ‘Varies’ if applicable.
13. Complete Box 16 with the rate per hour, indicating if it varies.
14. In Box 17, state actual hours worked per day, noting any variations in handwriting.
15. Include the number of days worked per week in Box 18 and indicate any variations.
16. For Box 20, write ‘Unknown’ in the categories of Meals, Lodging, and 2nd Income.
17. In Box 21, select ‘No’ as there are no apprentice positions currently.
18. For Box 22, describe how the injury occurred in detail.
19. In Box 23, specify the injury or illness sustained.
20. Indicate if the injury occurred on employer's premises in Box 25.
21. Fill in the tools or substances involved in Box 24.
22. Log the date of the first day of lost time in Box 26.
23. In Box 27, check the appropriate box regarding employer-paid lost time on the day of injury.
24. Leave Box 30 blank if the employee has not yet returned to work.
25. Fill in Box 43 with one witness name and phone number.
26. Upon completion, you may save changes, download, or print the form for submission.

Complete your UMD form online now to ensure prompt processing of your report.