Get First Report Of Injury (pdf Fill-in) - University Of Vermont - Uvm

Filing a First Report of Injury is a critical step in documenting workplace incidents. This guide provides clear, step-by-step instructions to help you complete the University of Vermont's form accurately, ensuring that all necessary information is included for prompt processing.

Follow the steps to accurately complete the First Report of Injury form

1. Click ‘Get Form’ button to obtain the form and open it for editing.
2. Fill in the 'Legal Name' field with the employee's full name. This should be the name as it appears on legal documents.
3. In the 'Business Name' section, enter 'University of Vermont and State Agricultural College'. Ensure accuracy in name spelling.
4. Complete 'Mail Address' by providing the street address: 284 East Ave, Burlington, VT 05405.
5. If the location differs from the mail address, fill in the 'Location of Accident' with the specific site of the incident.
6. Indicate the 'Nature of Business' by listing the main products or services offered by your organization.
7. In the 'Name' section, provide the employee’s first name, last name, and middle initial, if applicable.
8. Indicate whether the employee regularly works in a department with 10 or more employees.
9. Enter the employee’s Social Security Number, Date of Birth, and Home Address to establish their identity.
10. Provide 'Work Phone Number' and contact details so that any follow-up can occur easily.
11. Fill in the 'Job Title' and 'Dept' fields to describe the employee's role.
12. Complete the 'Wages' information, including values for hours per day, days per week, and any additional benefits such as board or lodging.
13. Document the date, time, and location of the accident thoroughly, including details of shifting schedules.
14. Describe the machinery or tools involved in causing the injury and indicate if the incident occurred on company premises.
15. Explain how the accident occurred by describing the events leading up to it.
16. In the 'Describe the injury' field, specify the nature of the injury and the part of the body affected.
17. Answer whether there was lost time from work and provide any necessary details about medical treatment.
18. If applicable, fill out insurance and claim administrator information at the bottom of the form.
19. Once all fields are completed, review the form for accuracy before saving your changes. You can then download, print, or share the completed form as needed.

Begin filling out your First Report of Injury form online today to ensure proper documentation.