If you have been injured or become ill from a work-related cause, complete this form documenting the circumstances within ONE BUSINESS DAY regardless of whether you seek medical treatment. Click the "Submit" button to start filling out the form.
If seeking medical treatment, complete the following and attach at the end of this form:
First Report of Injury, Occupational Disease, or Death (FROI) (.pdf)
Medical Release Form (.pdf)
Supervisor Statement of Employee Injury or Illness Report
Witness Statement of Employee Injury or Illness Report