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

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 or Chain of commandHuman Resources

Supervisor

If you do not know the answer to a question, leave it blank or type "Unknown"
Employee Legal Name*

Legal First NameLegal Last Name
Employee Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Employee Email*
example@example.com
Company*
Employee's normal location *
Employee's normal program*
Injury Details
Date of injury*

MonthDayYear
Date
Date that the Supervisor was notified of the injury*

MonthDayYear
Date
What time did the injury occur? *

Hour Minutes

AM/PM Option
What time did the Employee's shift start?*

Hour Minutes

AM/PM Option
Did the Employee leave work early?*

YesNo
What time did the Employee leave work?*

Hour Minutes

AM/PM Option
When was the shift scheduled until?*

Hour Minutes

AM/PM Option
Location where injury occurred *
Program where injury occurred*
Medical treatment sought by the Employee*

No medical treatment neededEmergency room visitClinic/ urgent careHospitalized overnight
Hospital name and address*
Address where injury occurred

Street Address

Apartment or Unit Number

CityState

Zip Code
What is the injury?*
Describe how the incident occured*

0/100
Witness to the injury
Witness phone number
Please enter a valid phone number.Format: (000) 000-0000.
Supervisor Legal Name*

Legal First NameLegal Last Name
Supervisor Email*
example@example.com
Supervisor Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.

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/
Person Completing the Form*

Legal First NameLegal Last Name
Person Completing the Form Signature*

Clear
Date of Signature of person completing the form*

MonthDayYear
Date
Human Resources Representative*

Legal First NameLegal Last Name
Human Resources Representative Email*
example@example.com
Human Resources Representative Signature*

Clear
Date of Signature of Human Resources representative*

MonthDayYear
Date
Please verify that you are human*
Should be Empty:

Supervisor