CRG - Kentucky FROI

Kentucky Worker's Compensation - First Report of Injury or Illness (FROI)
Location name*
Name (last, first, middle)*
Date of birth*

MonthDayYear
Social Security Number
Please ask the team member for this information
Phone number*
Team member phone number
Sex*

MaleFemaleUnknown
Address

Team member mailing address; add apartment number or P.O. Box, if applicable

Street Address Line 2

CityState

ZIP code
Occupation/job title*
Date hired*

MonthDayYear
Date
Employment status
State of hire*
Hourly pay rate (if known)
Date of injury/illness*

MonthDayYear
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?*

YesNo
Department or location where accident/illness/exposure occurred?*
Time of occurrence*

Minutes

AM/PM Option
Date employer notified*

MonthDayYear
Restaurant contact name*
Restaurant contact phone number*
Please enter a valid phone number
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?*

YesNo
Were the safeguards or safety equipment used?*

YesNo
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
Date administrator notified*

MonthDayYear
Date prepared*

MonthDayYear
Preparer's name and title*
Preparer's email *
example@example.com
Preparer's phone number*
Please enter a valid phone number
If your Team Member declines to seek treatment

Upload or take a photo of the Declination Form
File Upload

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Kentucky Worker's Compensation - First Report of Injury or Illness (FROI)

If your Team Member declines to seek treatment