• Workers' Compensation First Report of Injury (FROI)- Supervisor

    Fill out this form to report first report of injury. The submission will route to Human Resources for review. For questions, please contact Andrea Hagen at ahagen@orionassoc.net or 763-450-5008. 
  • Select your role*

  • Supervisor

    If you do not know the answer to a question, leave it blank or type "Unknown"
  • Format: (000) 000-0000.

  • Injury Details

  • Date of injury*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date that the Supervisor was notified of the injury*
     - -
    2 digit month, 2 digit day, 4 digit year
  • What time did the injury occur? *
  • What time did the Employee's shift start?*
  • Did the Employee leave work early?*
  • What time did the Employee leave work?*
  • When was the shift scheduled until?*
  • Medical treatment sought by the Employee*
  • 0/100
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Human Resources

  • Employment Information

  • Employee Status*
  • Employee Date of Hire*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Employee Personal Information

  • Employee Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Employee Martial Status*

  • Time Lost Due to Injury

  • First day of missed work
     - -
    2 digit month, 2 digit day, 4 digit year
  • Return to Work Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Employee Works*

  • Signatures

    I understand and accept that my electronic signature will be as valid as a handwritten signature and considered original to the extent allowed by applicable law. Please see the Consumer Consent Disclosure at https://www.jotform.com/consumer-consent-disclosure/
  • Date of Signature of person completing the form*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date of Signature of Human Resources representative*
     - -
    2 digit month, 2 digit day, 4 digit year
  •  
  • Should be Empty: