Indiana Worker's Compensation - First Report of Injury (FROI)
Cafe 251
Name (last, first, middle)
*
Date of birth
*
/
Month
/
Day
Year
Date
Social Security Number
Phone number
Team member phone number
Format: (000) 000-0000.
Gender
*
Male
Female
Unknown
Address (number and street, city, state, ZIP code)
*
Team member mailing address; add apartment number or P.O. Box, if applicable
Occupation/job title
*
Date hired
*
/
Month
/
Day
Year
Date
Employment status
Please Select
Active
Terminated
State of hire
*
Hourly pay rate (if known)
Location name
*
Incident location address
*
Date of inj./exp.
*
/
Month
/
Day
Year
Date
Date employer notified
*
/
Month
/
Day
Year
Date
Type of injury/exposure
*
Last work date
*
/
Month
/
Day
Year
Date
Time workday began
*
Hour Minutes
AM
PM
AM/PM Option
Part of body
*
Please indicate if left or right (when applicable)
Return to work date (if known)
/
Month
/
Day
Year
Date
Injury/exposure occurred on employer's premises?
Yes
No
Name of restaurant contact
*
Phone number of restaurant contact
*
Format: (000) 000-0000.
Department or location where accident/exposure occurred
*
All equipment, materials, or chemicals involved in accident
*
Specific activity engaged in during accident/exposure
*
Work process employee engaged in during accident/exposure
*
How injury/exposure occurred. Describe the sequence of events and include any relevant objects or substances
*
Name of physician/health care provider (if known/if applicable)
Hospital or offsite treatment (name and address if known/if applicable)
Name of witness (if applicable)
Telephone number
Phone number of witness
Format: (000) 000-0000.
Name of preparer
*
Preparer title
*
Preparer email
*
example@example.com
Preparer telephone number
*
Phone number of person completing the form
Format: (000) 000-0000.
Date prepared
*
/
Month
/
Day
Year
Date
Date administrator notified
*
/
Month
/
Day
Year
Date
If your Team Member declines to seek medical treatment
Upload or take a photo of the Declination Form
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