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First Report of Injury

Complete a First Report of Injury on all employees that are injured at work. Original First Report of Injury must be sent in next available green bag.

Name of Person Injured

School Name Where Injured Person Works

Did the injured person lose time due to the injury

Yes No

If yes, fax completed First Report of Injury to Patti Wells at 651.293.5322 immediately. If no, send original First Report of Injury in the next available green bag.

Did injured person go to the doctor

Yes No

If yes, fax completed First Report of Injury to Patti Wells at 651.293.5322 immediately. Fax doctor's slip as soon as it is received. If no, send original First Report of Injury in the next available green bag.

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