North Dakota > Workers Comp
First Report Of Injury SFN 2828 - North Dakota
| First Report Of Injury Form. This is a North Dakota form and can be used in Workers Comp . |
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FIRST REPORT OF INJURY SFN 2828 (08/2012) 1600 EAST CENTURY AVENUE, SUITE 1 PO BOX 5585 BISMARCK ND 58506-5585 Telephone 1-800-777-5033 Toll Free Fax 1-888-786-8695 TTY (hearing impaired) 1-800-366-6888 Fraud and Safety Hotline 1-800-243-3331 www.WorkforceSafety.com PLEASE PRINT OR TYPE USING BLACK OR BLUE INK AND RETURN TO WSI. Please see reverse side for Fraud Warning and other information. Claim Number Worker's Name Social Security Number Injury Date Time of Injury Birth Date AM PM Marital Status Sex F Single Married M Worker's Home/Cell Phone Number SECTION 1 Completion of this section is required Worker's Mailing Address (Street Address, PO Box Number) City Body Part Injured (Example: Left 2nd/middle finger, right shoulder, left ankle.) State Zip What was the nature of the injury or illness? (Example: chemical burn left hand, broken left leg, carpal tunnel syndrome in left wrist.) Tell us how the injury occurred and what the worker was doing before the incident (give details). (Example: "Worker was driving lift truck with pallet of boxes when the truck tipped, pinning driver's left leg under drive shaft." "Worker developed soreness in left wrist over time from daily computer key entry.") Name of Treating Doctor(s) Clinic/Hospital E. R. Visit Yes No City Overnight Stay Yes No State Zip Date of First Treatment N/A Address Employer's Name Employer's Address If job site, list location - (city, county, state, and zip) Employer's Premises Job Site City Time Worker Began Shift AM PM Yes No Has or will the incident cause you to miss five or more Yes No days of work? Doctor's Phone Number What is the worker's occupation? (job title or duties) State Zip Employer's Phone Number Date Hired When did worker last work in ND? Date employer notified and person you notified: Have you had prior problems or injuries to that part of the body? SECTION 2 Worker Completion Witness(es) to the Injury Address of Witness(es) I understand and agree that North Dakota law determines all my rights and obligations to and from WSI. I authorize any medical provider or facility, any insurance company, including workers' compensation relating to work injuries, any law enforcement or military agency, any government benefit agency including the Social Security Administration, and any educational agency or institution to release to WSI, its agents and attorneys, any and all information or records, including records pertaining to mental health, alcohol, or drug abuse, and HIV/AIDS/AIDS related illness. I authorize WSI to release any information or records about my claim to third parties or their insurers for the purpose of resolving claims against third parties. I authorize the release of any medical information related to my claim to my employer. Worker's Signature Date Signed In addition to myself, I authorize WSI to release information on my claim to: (please print) First Name Last Name Relationship Type of Injury (fracture, bruise, cut, etc.) Has the incident caused the worker to miss five or more Yes No days of work? Diagnosis condition based upon objective medical findings: Diagnosis code: Yes No If yes, please provide details. Date of First Treatment SECTION 3 Medical Provider Completion Has the worker had any prior problems or injuries to that part of the body? Date worker may return to work: Sedentary 10 lbs Without work restrictions With the following restrictions (list) Please complete the Physical Lifting Demand Level below see guide on reverse side. Light 20 lbs Medium 50 lbs Heavy 70 lbs Prognosis and anticipated length of medical treatment: Other instructions and/or limitations including prescribed medications or PT order: The above restrictions are in effect until: Re-evaluation date: Date Signed Time: Physician's Federal Tax ID No. Has the incident caused the worker to miss five or more days of Yes No work? First day worker lost wages due to work injury: Physician's Signature Employer Account Number Worker's Rate Class Causation Code (See reverse) Worker Status: Full Time; OSHA Log Number (See reverse) SECTION 4 Employer Completion Is worker a corp. officer, owner, partner, spouse or child Yes No under age 22? Hourly Rate $ Hours Worked Per Week Part Time; Seasonal; Temporary N/A Gross Earnings YTD $ From to Yes No No Job description submitted or attached? Yes No Date employer notified and person notified Date of Death ( If applicable) Has the worker had any prior problems or injuries to that part of the body If yes, did the worker opt out? Do you have a Designated Medical Provider (DMP)? Yes Yes No If you question this claim, state reason (continue on back) or attach additional information. Employer's Signature Title Date Signed American LegalNet, Inc. www.FormsWorkFlow.com Any person claiming benefits or compensation from WSI who files a false claim, or makes a false statement, or fails to notify WSI as to the receipt of income or an increase in income from employment, in connection with any claim or application for workers' compensation benefits will forfeit any future benefits and may be guilty of a felony which is punishable by imprisonment, substantial fines, or both. These criminal penalties are applicable to all persons dealing with the Fund, including injured workers, employers, medical providers, and attorneys. To report an instance of fraud, contact the ND Fraud and Safety Hotline at 1-800-777-5033.Additional information: For medical provider use: Physical Demand Level Sedentary Light Medium Heavy Occasional (0-3 Hours) 10 lbs. 20 lbs. 50 lbs. 70 lbs. Frequent (3-6 Hours) Negligible 10 lbs. and/or Walk/Stand/Push/Pull of Arm/Leg controls 20 lbs. 50 lbs. Constant (6-8 Hours) Negligible Negligible and/or Push/Pull of Arm/Leg controls while seated. 10 lbs. 20 lbs. For employer use: Causation Codes: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. Contact with object and/or equipment Fall to lower level Fall on same level Slip, trip, or loss of balance without fall Overexertion Overexertion lifting Repetitive motion Exposure to harmful substances Transportation accident Fire and/or explosion Assault and/or violent act For more information regarding the OSHA Log number (OSHA 300 Reference Number), visit http://www.osha.gov/recordkeeping/index.html . American LegalNet, Inc. www.FormsWorkFlow.com
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