Workers' Compensation Forms
Reporting a workplace injury, illness or incident.
PLEASE NOTE: The following information is only for those State of Minnesota entities participating in the Department of Administration's Workers' Compensation Program for workers' compensation coverage. All others should refer to the MN Department of Labor & Industry at: www.dli.mn.gov/WorkComp.asp.
State agencies and other covered entities under the Workers' Compensation Program, please use iRISK for reporting incidents and reporting a workplace injury. Please continue all other existing processes for gathering and investigating workplace incidents. Here are instructions on how to report using iRISK.
The sample training documents below and the video demonstration were creating using a test account. Please do not attempt to copy and paste the URL from the screens in these documents as it will not work. You need to access the Incident Reporting process through Self Service, and you need to access iRISK through the live production URL. We send you the iRISK URL along with your log in ID and password the first time you need to access iRISK to complete the incident reporting process. You can then create a short cut link to iRISK on your desktop.
Please also know that some screen shots will appear slightly different in the live production account, but the process is the same as outlined in the instructions here.
Please note: You may need to load additional software (GoToMeeting codec) to view the iRISK training videos.
Use the following information and forms for preparing and/or filing information regarding workplace injuries, illnesses, or incidents:
The Supervisor's Injury/Illness/Incident Reporting & Workers' Compensation
Rev. 7/13/10 (pdf) identifies the critical steps Supervisors must take to report a work related injury, illness, or incident. The checklist references the forms found below.
The following forms are to be completed and submitted as soon as possible but no later than 24 hours to your agency Workers' Compensation Coordinator. Please refer to the Supervisor's Checklist for more detailed information.
WORD FORMAT WARNING
You cannot send completed word documents directly from your web browser. You must save the document to your computer then attach it to an email.
To use “Word Format” forms, right click on the link and use the "save as" command to save the document to your computer or network drive. Open it from that location and complete it. Be sure to save the file again. Attach the completed document to an e-mail for distribution or print it. Unfortunately MS Word does not allow spell check within form fields so do your best and don't worry to much about spelling errors.
To use “pdf” forms, simply print the form, complete it entirely and then route it for distribution.
Rev. 2/1/09 (pdf) - This form should be given to the injured worker PRIOR to collection of any data needed to fill out and file an FRI. This form is used to ensure compliance with the Minnesota Government Data Practices Act.
Rev. 3/1/09 (Word format) - This form is to be completed by individuals reporting an injury, illness, or incident. Supervisors should have the person reporting the incident compete the form as soon as possible after the incident. Supervisors must also complete the Injury/Illness/Incident Data Form below.
Rev. 3/1/09 (Word format) - 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. 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. (pdf)
Rev. 2/1/09 (Word format)- This form is used by the supervisor to conduct an investigation of the injury, illness, or incident. The investigation should identify contributing factors that permitted the event to occur and should identify actions that will be taken to prevent reoccurrence. (pdf)
Rev. 7/22/09 (pdf)- This form (or 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.
Rev. 3/10 (pdf) - This is an essential packet of information that must be given to workers reporting a possible work related injury or illness.
Rev. PS2503-02 ( pdf) - FOR MOTOR VEHICLE CRASHES ONLY- This form is used to obtain a copy of the motor vehicle crash report.
Rev. 6/08 (pdf) - This form should be obtained by agencies when employees return to the job following a work-related injury. Most health care providers have their own Report of Work Ability form. If a health care vendor does not have their own form you can print this form for their use.
Further information about the workers' compensation process can be found in the Supervisor's Workers' Compensation Handbook (pdf).
Workers' Compensation Coordinator Resources
Rev. 8/1/09 (Word Format) - This checklist identifies the minimum critical steps Workers' Compensation Coordinators should take to report and manage a work related injury, illness, or incident. (pdf)
Handling non-SEMA4 workers
The following two forms are to be completed by agency Workers' Compensation Coordinators for reporting work related injuries or illnesses involving employees that are not enrolled in SEMA4. Please complete the following forms and submit to the Workers' Compensation Program with all forms indicated above.
(Word format) - This form is only to be used by agency Workers' Compensation Coordinators to report injuries or illnesses reported by employees that do not have a SEMA4 employment record (e.g. agencies not using SEMA4, student workers, volunteers). (pdf)
(pdf) - This form is only to be submitted by those organizations who do not have access to the SEMA4 system and who require the assistance of the Department of Administration to provide workers' compensation coverage. This form is used to document employee's earnings when earnings are irregular, difficult to determine, or consist of overtime, differential or other special pay in at least one-half of the work weeks in the 26 weeks preceding the date of injury. If the employee's work status has changed during the 26 week period (e.g., full-time to part-time, part-time to full-time, promotion, demotion or is a new hire) provide wages only since the date of the most recent work status change and note the type of change. For organizations that can file the First Report of Injury through the SEMA4 system, a 26 week earnings report will be generated automatically.
Questions or assistance?
If you have questions or need assistance related to preparing/filing the forms to report a possible work related injury or illness, or need help with workers' compensation claims management issues, please contact John Sargent via e-mail at firstname.lastname@example.org. Or call John Sargent at 651-201-3031.