The Commonwealth of Massachusetts

Department of Industrial Accidents – Department 101

600 Washington Street – 7th Floor, Boston, Massachusetts 02111

Info. Line 800-323-3249 ext. 470 in Mass. Outside Mass. - 617-727-4900 ext. 470

http://www.mass.gov/dia

Employer's first report of injury or fatality

This form must be filed by the employer in the event of an injury that results in death or five or more calendar days of total or partial incapacity from earning wages. Instructions and codes on the reverse side - please print legibly or type - unreadable forms will be returned.

Employee information

1. Employee's name (Last, First, MI):

2. Home telephone number:

3. Social Security number*:

4. Sex:

M F

5. Home address (No., Street, City, State & Zip Code):

6. Marital status:

M S

7. No. of dependents:

8. Date of hire (mm/dd/yyyy):

9. Date of birth (mm/dd/yyyy):

10. Average weekly wage:

$ Estimated Actual

Employer information

11. Employer's name:

12. Federal Tax I.D. number:

13. Employer's address (No., Street, City, State & Zip Code):

14. Employer's telephone number:

15. Industry code (See reverse side):

16. Workers' compensation insurance carrier and tel. no. (not local agent/administrator):

17. W.C. Policy number:

18. Self-insured?

Yes No If yes, self-insurer number:

19. Business type:

Injury information

20. Date of injury (mm/dd/yyyy):

21. Was employee injured on employer's premises?

Yes No

22. Location of injury if not on employer's premises:

23. First day of total or partial incapacity to earn wages (mm/dd/yyyy):

24. Fifth day of total or partial incapacity to earn wages (mm/dd/yyyy):

25. If employee has died, date of death (mm/dd/yyyy):

26. Source of injury (chemicals, machinery, etc.):

27. Briefly describe how injury/exposure occurred and body part(s) involved:

28. Person to whom injury was reported (list position):

29. Date reported (mm/dd/yyyy):

30. Date reported as work related (mm/dd/yyyy):

31. Injury code(s)

a.to body part

b.to body part

c.to body part

Body part code(s)

32. Witness(es) to injury - give full name(s), if none state as such:

33. Has employee returned to work?

Yes No

34. Date employee returned to work (mm/dd/yyyy):

35. Employee's regular occupation:

36. Has employee returned to regular occupation?

Yes No

37. Employer's name (see instructions on reverse side):

38. Title:

39. Employer's signature (see instructions on reverse side):

40. Date prepared (mm/dd/yyyy):