Kentucky Worker's Compensation - First Report of Injury or Illness (FROI)
Location name
*
Please Select
Mesh Louisville
BRU Lexington
BRU Fort Mitchell
Name (last, first, middle)
*
Date of birth
*
-
Month
-
Day
Year
Social Security Number
Please ask the team member for this information
Phone number
*
Team member phone number
Format: (000) 000-0000.
Sex
*
Male
Female
Unknown
Address
Team member mailing address; add apartment number or P.O. Box, if applicable
Street Address Line 2
City
State
ZIP code
Occupation/job title
*
Date hired
*
-
Month
-
Day
Year
Date
Employment status
Please Select
Active
Terminated
State of hire
*
Hourly pay rate (if known)
Date of injury/illness
*
-
Month
-
Day
Year
Type of injury/illness
*
Ex: burn, laceration, etc.
Body part affected
*
Please indicate if left or right (when applicable)
Did injury/illness/exposure occur on employer's premises?
*
Yes
No
Department or location where accident/illness/exposure occurred?
*
Time of occurrence
*
Minutes
AM
PM
AM/PM Option
Date employer notified
*
-
Month
-
Day
Year
Restaurant contact name
*
Restaurant contact phone number
*
Please enter a valid phone number
Format: (000) 000-0000.
All equipment, materials, or chemicals employee was using when accident/illness/exposure occurred
*
Specific activity the employee was engaged in when the accident/illness/exposure occurred
*
Work process the employee was engaged in when accident/illness/exposure occurred
*
How injury or illness/abnormal health condition occurred. Describe the sequence of events and include any objects or substances that directly injured the employee or made the employee ill
*
Were safeguards or safety equipment provided?
*
Yes
No
Were the safeguards or safety equipment used?
*
Yes
No
Hospital or offsite treatment facility (name and address if known/if applicable)
Name of witness (if applicable)
Phone Number (if applicable)
Phone number of witness
Format: (000) 000-0000.
Date administrator notified
*
-
Month
-
Day
Year
Date prepared
*
-
Month
-
Day
Year
Preparer's name and title
*
Preparer's email
*
example@example.com
Preparer's phone number
*
Please enter a valid phone number
Format: (000) 000-0000.
If your Team Member declines to seek treatment
Upload or take a photo of the Declination Form
File Upload
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Preview PDF
Submit
Should be Empty: