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First Report of Injury:. Changed a bit in January 2002, people still think of this as “new.” Changes were driven by changes in regulations. First Report of Injury. A report must be made for any workplace injury or illness incident that occurs.

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first report of injury

First Report of Injury:

Changed a bit in January 2002, people still think of this as “new.”

Changes were driven by changes in regulations.

first report of injury1
First Report of Injury
  • A report must be made for any workplace injury or illness incident that occurs.
  • The supervisor must complete both sides of the form within 24 hours of the incident.
  • A copy of the completed form must be sent to REM within 48 hours of the incident.
liberty mutual
Liberty Mutual
  • Lib Mut is the University’s Claims Administrator for Worker Compensation and Occupational Medical claims.
  • The supervisor is to call Liberty Mutual ONLY if the employee:

1) Has lost work time, OR.

2) Has obtained medical treatment.

first report of injury form front left
First Report of Injury: Form Front Left
  • See the small box on the left side of the page.
  • Title, phone, date of Supervisor.
  • It is NOT OK for the Supervisor to tell the employee to “fill it out and give it to me to sign.”
first report of injury front center
First Report of Injury: Front Center
  • Employee Name, Address, Date of Birth, Date Hired, Gender
  • Physician Name, Medical Facility name, ER?, overnight/inpatient? (writing N/A is acceptable if true)
first report of injury front right
First Report of Injury: Front Right
  • Info about case
  • What was employee doing before?
  • What happened?
  • What is injury or illness?
  • What object/substance directly harmed the employee?
  • Time/date of death?
first report of injury back
First Report of Injury: Back
  • Purdue pays Liberty Mutual about 1 M$ per year simply to administer (not pay) the worker comp and occupational medical insurance claims.
  • The form back is information that is required by Liberty Mutual, REM, or by Purdue Compensation and Benefits
first report of injury back1
First Report of Injury: Back
  • Info must be accurate
  • If claim not paid, bill will be sent to employee (if there is a bill).
  • If employee doesn’t pay, the bill will be turned over to a collection agency.
first report of injury back2
First Report of Injury: Back
  • Note particularly:
  • Root cause of accident
  • Corrective action taken
  • Be careful to document this corrective action.
first report of injury form finished
First Report of Injury: ….form finished
  • MAKE A COPY -- never ever send your only copy of something important to someone else.
  • send the copy to REM and keep the original.
  • Supervisor must have the original, completed form in hand while making the phone call.
the phone call
The phone call
  • Purdue pays Liberty Mutual approx 1 m$ per year ….
  • Every phone call that is made erroneously costs a little more.
  • Over the year, thousands of dollars worth of phone calls are made.
the phone call1
The phone call
  • Supervisor must make the phone call….
  • IFF the employee received medical treatment or lost time BEYOND the date of the injury
  • Supervisor must have the completed form in hand when making the call.