MD 1A-1 2002-2024 free printable template

A Form First Report of Injury (FFRI) is a document used to report any work-related injury or illness that requires medical treatment beyond first aid. It is typically completed by the employee and their supervisor and submitted to the employer or workers’ compensation insurance carrier. The form includes information about the injury, including the date, time, and location of the incident, as well as details about the injury itself. It also includes information about the employee, such as their name, contact information, and Social Security number.

The employer is required to file a First Report of Injury with their state workers' compensation agency within a certain timeframe after an employee has suffered a work-related injury or illness.

1. Gather the information you will need to complete the form. This information includes the injured worker's name, date of birth, Social Security number, address, telephone number, and date of injury. 2. Provide the employer's name, address, and telephone number. 3. Describe the injury or illness in detail, including the date, time, and circumstances of the incident. 4. Provide details of the medical treatment received, including the name, address, and telephone number of the facility or doctor. 5. Indicate whether the injured worker is able to continue working and, if not, the expected date of return to work. 6. List any witnesses to the incident and provide their contact information. 7. Sign and date the form. 8. Submit the form to the appropriate state or federal agency.

Form First Report of Injury (FFR) is a document used in the workplace to report an injury or illness that occurs on the job. It is a legal requirement for employers to complete this form and submit it to the relevant regulatory body within a certain timeframe. The FFR is used to ensure that injured employees receive appropriate medical treatment and benefits, as well as to ensure compliance with the relevant workplace health and safety regulations.

The penalty for late filing of Form First Report of Injury (FROI) is a civil monetary penalty of up to $7,000 per violation. The penalty may be assessed to the employer, the insurer, the third party administrator, or the self-insured.

The specific information required on a first report of injury form may vary depending on the jurisdiction and the company's internal policies. However, some common information that is typically included on such forms may include: 1. Employee information: Name, address, contact details, job title, department, and other relevant identification information of the injured employee. 2. Employer information: Name, address, contact details, and any other relevant identification information of the employer or company. 3. Date and time of the injury: The specific date and time at which the injury occurred or was first reported. 4. Location of the injury: The specific place or location where the incident occurred. 5. Description of the incident: A detailed account of how the injury occurred, including any contributing factors or events leading up to the incident. 6. Type and extent of injury: The nature and severity of the injury sustained, including specific details such as body parts affected, medical diagnosis, and extent of medical treatment required. 7. Witnesses: Any witnesses to the incident and their contact information. 8. Supervisor's report: Details of the supervisor or manager present at the time of the incident, including their observations and actions taken. 9. Reporting time frame: Whether the injury was reported within the required time frame or if there was any delay in reporting. 10. Other relevant information: Any other pertinent details related to the incident or injury, such as prior medical conditions, safety precautions in place at the time, or potential third-party liability. It is important to consult with local laws and regulations or company policies to ensure that all required information is included on the first report of injury form.

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