What is a First Report of Injury and when must it be filed?

A First Report of Injury (FROI) is the initial documentation of a workplace injury or illness, required for workers' compensation claims. Employers must typically file within 24-72 hours of learning of the injury (varies by state). Medical providers complete the medical portion documenting injury details, diagnosis, and work status.

What information is required on a workers' comp injury report?

Required information includes: employee demographics and job information, employer details, date/time/location of injury, detailed description of how injury occurred, body parts injured, diagnosis with ICD-10 codes, treatment provided, work status (full duty, modified duty, or out of work), and expected duration of disability if applicable.

Who is responsible for filing the First Report of Injury?

The employer is responsible for filing the FROI with their workers' comp insurance carrier and, in most states, with the state workers' compensation board. The treating physician provides medical documentation. Employers should have a process for injured workers to report injuries and for supervisors to complete employer portions promptly.

What determines if an injury is covered by workers' compensation?

Workers' comp covers injuries or illnesses arising out of and in the course of employment. This includes injuries during work tasks, on work premises, and during work-related travel. It typically excludes: self-inflicted injuries, injuries during commute to/from work, injuries while intoxicated (varies by state), and injuries during personal activities.

How does work status affect workers' compensation benefits?

Work status determines benefit type: 'Out of work' qualifies for temporary total disability (TTD) benefits. 'Modified duty' may qualify for temporary partial disability if earning less. 'Full duty' means no disability benefits. Be specific and accurate about work restrictions—overly restrictive notes may prolong disability unnecessarily; insufficiently restrictive notes may cause re-injury.

Workers' Comp First Report of Injury Template

Quick-Use Checklist

Use this checklist before finalizing documentation.

Confirm visit context, chief concern, and date/time of service before note completion.

Capture required exam/findings and plan elements that support coding specificity.

Document medical decision making clearly to reduce denials and audit risk.

WORKERS' COMPENSATION: FIRST REPORT OF INJURY 1. EMPLOYEE INFORMATION Name: [Employee Name] | DOB: [Date of Birth] | SSN: [Last 4 SSN] Address: [Employee Address] Job Title: [Job Title] * 2. EMPLOYER INFORMATION Company Name: [Employer Name] Address: [Employer Address] * 3. INJURY DETAILS Date of Injury: [Date] | Time of Injury: [Time] Date Reported: [Date] Location of Accident: [Where did it happen?] Description of Accident:

[Describe exactly how the accident occurred. Be specific about machinery, heavy objects, slips/falls, etc.]

Body Part(s) Injured:

[ ] Head/Neck
[ ] Back/Spine
[ ] Upper Extremity: [R / L]
[ ] Lower Extremity: [R / L]
[ ] Other: [Specify]

* 4. MEDICAL TREATMENT Did employee seek treatment? [Yes / No] Initial Provider: [Practice/Hospital Name] Treatment Date: [Date] Diagnosis:

[Enter Diagnosis Codes/Description]

Work Status:

[ ] Return to work: No restrictions
[ ] Return to work: Modified duty (See Note)
[ ] Out of work until: [Date]

* 5. SIGNATURES Employee Signature: __________________________ Date: [Date] Supervisor Signature: __________________________ Date: [Date] * Submit this form to your Insurance Carrier immediately.

Workers' Comp First Report of Injury Template

Quick-Use Checklist

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