Reporting a workplace injury, illness or incident. 

PLEASE NOTE: The following information is only for those State of Minnesota entities participating in the Department of Administration’s Workers’ Compensation Program for workers’ compensation coverage.  All others should refer to the MN Department of Labor & Industry at: www.doli.state.mn.us/workcpm.html.

Use the following information and forms for preparing and/or filing information regarding workplace injuries, illnesses, or incidents:

Supervisor’s Checklist

The Supervisor’s Injury/Illness/Incident Reporting & Workers’ Compensation Checklist (Rev. 8/1/09) identifies the critical steps Supervisors must take to report a work related injury, illness, or incident.  The checklist references the forms found below.

Forms

The following forms are to be completed and submitted as soon as possible but no later than 24 hours to you agency Workers’ Compensation Coordinator.   Please refer to the Supervisor’s Checklist for more detailed information.

WORD FORMAT WARNING
You can not send completed word documents directly from your web browser. You must save the document  to your computer then attach it to an email.

To use “Word Format” forms, right 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. Be sure to save the file again. Attach the completed document to an e-mail for distribution or print it. Unfortunately MS Word does not allow spell check within form fields so do your best and don’t worry to much about spelling errors.   

Employee statement regarding injury/illness Rev. 3/1/09 (Word format)  – This form is to be completed by individuals reporting an injury, illness, or incident.  Supervisors should have the person reporting the incident compete the form as soon as possible after the incident.  Supervisors must also complete the Injury/Illness/Incident Data Form. (PDF format)

FRI Injury/Illness/Incident Data Form (IDF) Rev. 3/1/09 (Word format) – This form replaces the old First Report of Injury (FRI) and is used to collect the necessary information regarding an injury, illness, or incident that may be work related.  Please check with your agency Workers’ Compensation Coordinator to determine whether your office is using this form or an equivalent form designed by your agency. (PDF format)

Agency Claims Investigation Form Rev. 2/1/09 (Word format)– This form is used by the supervisor to conduct an investigation of the injury, illness, or incident.  The investigation should identify contributing factors that permitted the event to occur and should identify actions that will be taken to prevent reoccurrence. (PDF format)

Leave Supplement Form Rev. 7/22/09 (PDF format)– This form (or agency equivalent) is used by employees to document their decision to supplement their workers’ compensation payment with accrued but unused sick, vacation, or compensatory time.

Employee Information Packet Rev. 2/1/09 (PDF format) – This is an essential packet of information that must be given to workers reporting a possible work related injury or illness.

Department of Public Safety Crash Records Request Form Rev. PS2503-02 ( PDF format) - FOR MOTOR VEHICLE CRASHES ONLY- This form is used to obtain a copy of the motor vehicle crash report.

Report of Work Ability Form Rev. 6/08 (PDF format) - This form should be obtained by agencies when employees return to the job following a work-related injury. Most health care providers have their own Report of Work Ability form. If a health care vendor does not have their own form you can print this form for their use.

Further information about the workers’ compensation process can be found in the Supervisor’s Workers’ Compensation Handbook.

Workers’ Compensation Coordinator Resources

Coordinator Checklist Rev. 8/1/09 (Word Format) - This checklist identifies the minimum critical steps Workers’ Compensation Coordinators should take to report and manage a work related injury, illness, or incident.  

Handling non-SEMA4 workers
The following two forms are to be completed by agency Workers’ Compensation Coordinators for reporting work related injuries or illnesses involving employees that are not enrolled in SEMA4.  Please complete the following forms and submit to the Workers’ Compensation Program with all forms indicated above.

•  Non-SEMA4 Employee Details Form (Word format) – This form is only to be used by agency Workers’ Compensation Coordinators to report injuries or illnesses reported by employees that do not have a SEMA4 employment record (e.g. agencies not using SEMA4, student workers, volunteers). (PDF format)
   

• 26-Week Wage Information Form (PDF format) – This form is only to be submitted by those organizations who do not have access to the SEMA4 system and who require the assistance of the Department of Administration to provide workers' compensation coverage. This form is used to document employee’s earnings when earnings are irregular, difficult to determine, or consist of overtime, differential or other special pay in at least one-half of the work weeks in the 26 weeks preceding the date of injury. If the employee's work status has changed during the 26-week period (e.g., full-time to part-time, part-time to full-time, promotion, demotion or is a new hire) provide wages only since the date of the most recent work status change and note the type of change.  For organizations that can file the First Report of Injury through the SEMA4 system, a 26-week earnings report will be generated automatically.

Questions or assistance? 

If you have questions or need assistance related to preparing/filing the forms to report a possible work related injury or illness, or need help with workers’ compensation claims management issues, please contact John Sargent via e-mail at john.sargent@state.mn.us.  Or call John Sargent at 651-201-3031.

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