![]() ![]() Most health care providers have their own Report of Work Ability form. This form should be obtained by agencies when employees return to the job following a work-related injury. Report of Work Ability Form (PDF) - Online form on the Department of Labor and Industry website.This form is used to obtain a copy of the motor vehicle crash report. Department of Public Safety Crash Records Request Form (PDF) - Version PS2503-11įOR MOTOR VEHICLE CRASHES ONLY.This is an essential packet of information that must be given to workers reporting a possible work-related injury or illness.Employee Information Packet (PDF) - Revised April, 2021.This form (or an 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. Leave Supplement Form (PDF) - Revised July 22, 2009.The investigation should identify contributing factors that permitted the event to occur and should identify actions that will be taken to prevent future occurrences. This form is used by the supervisor to conduct an investigation of the injury, illness or incident. Agency Claims Investigation Form (Microsoft Word) - Revised January 2015 (Also available in PDF format).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. 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. First Report of Injury - Injury, Illness, Incident Data Form (IDF) (Microsoft Word) - Revised August 2015 (Also available in PDF format).Supervisors must also complete the Injury, Illness, Incident Data Form below. Supervisors should have the person reporting the incident compete the form as soon as possible after the incident. This form is to be completed by individuals reporting an injury, illness or incident. Employee statement regarding injury/illness (PDF) - Revised January 2015 (Also available in Microsoft Word format).This form is used to ensure compliance with the Minnesota Government Data Practices Act. This form should be given to the injured worker prior to collection of any data needed to fill out and file a first report of injury. Information and Privacy Statement (PDF) - Revised July 14, 2010.With PDF forms, simply print the form, complete it by hand and route for distribution. In most cases, Microsoft Word does not allow spell check within form fields so do your best and don't worry too much about spelling errors. ![]() Once completed, attach the document to an email or print it for sending. Note: When accessing Microsoft Word documents from your web browser, be sure to save a local copy to your computer or network drive before completing. Please refer to the Supervisor's Checklist for more detailed information. The following forms are to be completed and submitted to your agency Workers' Compensation Coordinator as soon as possible but no later than 24 hours after the incident. ![]()
0 Comments
Leave a Reply. |
AuthorWrite something about yourself. No need to be fancy, just an overview. ArchivesCategories |