Injury Reporting Forms

To initiate a workers’ compensation claim, the employee must notify their supervisor about the injury or illness as soon as possible. The supervisor then reports the incident to the Human Resources office, and completes and submits the forms described below. Anyone responsible for directing student employees or Graduate Assistants or any other employees, is considered a supervisor, for purposes of these reporting requirements.

Following is a brief discussion of the injury and illness reporting requirements.

A packet containing the forms and information needed to report an injury or illness and initiate the worker’s compensation process is available from the Human Resources office. The packet consists of a cover letter and five attachments. The forms must be completed and returned to the BSU Human Resources Office, within five calendar days of when the injury was reported to the supervisor. Please note that weekends and holidays are included as part of that time requirement. There is a fine for late reporting. Fines for late reporting will be charged back to the College or Department involved. You should have the reporting forms readily available in your Department or work area. Contact Human Resources at 1-218-755-3966 to get more forms or download them from the sites linked below.

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First Report of Injury Form

The first form in the packet is a First Report of Injury. It must be completed on all work-related injuries and illnesses that result in the need for medical treatment or lost time from work. The First Report of Injury must be accurate, complete, legible and received by Human Resources within five calendar days. Directions for completing the form are printed on its reverse side. This form is to be completed by the employee’s immediate supervisor, not the employee. DOER will process and forward a copy of the completed form to the employee.

Select the following link to download a Word version of the form.

First Report of Injury (FRI), Word document Format

To use this form, click on the link and use the “save as” command to save the document to your computer or network drive. Open it from that location and complete it by tabbing through the shaded areas and typing in the appropriate information. Be sure to save the file again. Attach the completed document to an e-mail for distribution or print it.

Agency Claims Investigation Form

The next form in the packet is the Agency Claims Investigation form. An investigation report must be completed for every accident. The information assists the claim specialist in conducting additional investigation in order to make a liability determination. As with the FRI, directions for completing this form are printed on its reverse side. It too is to be completed by the employee’s immediate supervisor and not by the employee.

Select the following link to access the form from DOER as a PDF document.

Agency Claims Investigation Form

To use this form; print it, complete it and forward it to the Human Resources office in Deputy, Box 1.

Information Privacy Statement

The final form is the Workers’ Compensation Program, Department of Administration Information and Privacy Statement. It explains to the employee how the information will be used in processing their workers’ compensation claim. This form should be signed and dated by the employee and returned with the other forms, by the supervisor, to the Human Resources office.