Wsi Ffirst Report Of Injury Form – Fill Out and Use This PDF

Claim Number

Worker’s Name

Social Security Number

Injury Date

Time of Injury

Birth Date

required

AM

PM

Worker’s Mailing Address

Sex

Marital Status

F

Single

Married

M

is

City

State

Zip

Worker's Home/Cell Phone Number

sectionthis

Body Part Injured (Example: Left 2nd/middle finger, right shoulder, left

What was the nature of the injury or illness? (Example: chemical burn left hand, broken left leg,

ankle.)

carpal tunnel syndrome in left wrist.)

of

Tell us how the injury occurred and what the worker was doing before the incident (give details). (Example: “Worker was driving lift truck with pallet of boxes when the truck

tipped, pinning driver’s left leg under drive shaft.” “Worker developed soreness in left wrist over time from daily computer key entry.”)

Completion

Name of Treating Doctor(s)

Clinic/Hospital

E. R. Visit

Overnight Stay

Date of First Treatment

Yes

No

Yes

No

N/A

Address

City

State

Zip

Doctor’s Phone Number

Employer’s Name

What is the worker’s occupation? (job title or duties)

Employer’s Address

City

State

Zip

Employer’s Phone Number

If job site, list location - (city, county, state,

Employer’s Premises

Time Worker Began Shift

When did worker last work in

Date Hired

and zip)

Job Site

AM

ND?

PM

Date employer notified and person you notified:

Have you had prior problems or injuries to that part of the body?

Yes

No

Completion

Witness(es) to the Injury

Address of

Witness(es)

Have you missed five or more days from work or are

release to WSI, its agents and attorneys, any and all information or records, including records pertaining to mental health, alcohol, or drug abuse, and HIV/AIDS/AIDS related illness. I authorize WSI to

you currently off work greater than five days?

Yes

No

I understand and agree that North Dakota law determines all my rights and obligations to and from WSI. I authorize any medical provider or facility, any insurance company, including workers’

compensation relating to work injuries, any law enforcement or military agency, any government benefit agency including the Social Security Administration, and any educational agency or institution to

Worker

release any information or records about my claim to third parties or their insurers for the purpose of resolving claims against third parties. I authorize the release of any medical information related to

my claim to my employer.

Worker’s Signature

Date Signed

In addition to myself, I authorize WSI to release information on my claim to: (please print)

First Name

Last Name

Relationship

Type of Injury (fracture, bruise, cut, etc.)

Date of First Treatment

Completion

Has the incident caused the worker to miss five or more

Diagnosis condition based upon objective medical findings:

days work or is currently off work greater than five days?

Diagnosis code:

Yes

No

Has the worker had any prior problems or injuries to that part of the body?

Yes

No If yes, please provide details.

Provider

Date worker may return to work:

Without work restrictions

With the following restrictions (list)

Please complete the Physical Lifting Demand Level below – see guide on reverse side.

Sedentary

10 lbs

Light

20 lbs

Medium

50 lbs

Heavy

70 lbs

Medical

Other instructions and/or limitations including prescribed medications or

Prognosis and anticipated length of medical treatment:

PT order:

The above restrictions are in effect until:

Re-evaluation date:

Time:

Physician’s Signature

Date Signed

Physician’s Federal Tax ID No.