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FROI First Report of Incident
First Report of Incident Spanish
Supervisor/Safety Report
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First Report of Incident (FROI)
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Employer
Name
Please provide employer name.
Address
Please provide address.
City
Please provide city.
State
Choose...
CT
NJ
NY
PA
Please select a state.
Zip
Please provide zip code.
Employee
Last Name
Please provide last name.
First Name
Please provide first name.
Middle Initial
Street Address
Please provide street address.
City
Please provide city.
State
Choose...
CT
NJ
NY
PA
Please select a state.
Zip
Please provide zip code.
Telephone
Please provide telephone number.
Date of Birth
SSN
Please provide SSN.
Date of Hire
State of Hire
Choose...
CT
NJ
NY
PA
Gender
Male
Female
Department
Please provide department.
Occupation
Please provide occupation.
ncci class code
Please provide ncci class code.
Marital Status
Choose...
Unmarried
Single/Divorced
Married
Separated
Unknown
Work Status
fulltime
parttime
Wage Rate
Please provide wage rate.
Pay Schedule
Weekly
Bi-Weekly
Monthly
Daily
Please provide Pay Schedule.
Days Woorked Per Week
1
2
3
4
5
6
7
full pay for date of injury
Yes
No
Employee_salary_continue
Yes
No
Email
Please provide valid email.
Occurrence / Treatment
Time Empply Began Work
Please provide start time.
AM/PM
AM
PM
Please select AM or PM.
Date of Injury
Please provide injury date.
Time of Injury
Please provide injury time.
AM/PM
AM
PM
Please select AM or PM.
Was time lost from work?
Yes
No
Please select if time was lost from work.
Last Work Date
Please provide last work date.
Date Employer Notified
Please provide date employer was notified.
Date Disability Began
Please provide date disability began.
Type of Injury
Please provide type of injury.
Body Part(s) Affected
Please provide affected body parts.
Did injury occur on employer's premises?
Yes
No
Please select if injury occurred on employer's premises.
Department or location where accident occurred
Zip_code_of_injury_site
All equipment, materials or chemicals employee was using when accident occurred
Specific activity the employee was engaged in when the accident occurred
Work process the employee was engaged in when accident occurred
How injury occurred - Describe the sequence of events
Date Returned to Work
Employee still out of work?
Yes
No
If Fatal - Date of Death
Safety equipment provided?
Yes
No
Safety equipment used?
Yes
No
Medical
Initial_Treatment
Please provide Initial_Treatment.
Name of Physician or Health Care Provider
Please provide health care provider name.
Address
Please provide address.
City
Please provide city.
State
Choose...
CT
NJ
NY
PA
Please select a state.
Zip
Please provide zip code.
Hospital or Offsite Facility
Facility Address
Facility City
Facility State
Choose...
CT
NJ
NY
PA
Facility Zip
Other
Witness Name
Witness Phone
Date Administrator/TPA Notified
Please provide Date Administrator/TPA Notified.
Date Report Prepared
Preparer's Name
Please provide preparer's name.
Preparer's Title
Please provide preparer's title.
Preparer's Email
Please provide valid email.
Preparer's Phone
Please provide preparer's phone.
Admin Password option 1
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