How to Complete and Submit the

First Report of Injury (FROI) Form

Getting StartedIf you see the yellow bar, select “Options” then select “Enable JavaScript for this document always”. if you see a purple bar continue on.

If you don't see a yellow or purple bar click the first graphic in the toolbar along the left margin.

Getting Started (2)

If data entry fields are not highlighted with several outlined in red as well, click the “Highlight Fields” button. Fields outlined in red require an entry before the form can be submitted.

Hovering your mouse pointer over the yellow encircled question mark ("?") near a field will open a popup window containing information to help you enter accurate information into that field.

Getting Started (3)

If you enter incorrectly formatted information in certain fields you will get an error window popup explaining the issue.

Department Number:*Enter the employee's 8-digit department number (SAP Org Unit). Preceding “0”s will populate automatically.

EMPLOYEE INFORMATION

Does the employee work in Physical Facilities Zones? If an employee is a part of Physical Facilities Zones, check yes. This information is useful for developing departmental injury statistics.

Supervisors Telephone:The Supervisor’s telephone number is used in case a workman’s compensation representative needs to contact the supervisor.

Person Completing Form:It is preferable that it be the supervisor, but it may be someone designated by the supervisor.

EMPLOYEE INFORMATION (2)

INCIDENT INFORMATIONThis is the section where specific details about the incident will be provided.

INCIDENT INFORMATION (2)

Date of Injury Or Illness: In some cases the injury is cumulative in nature (e.g. ergonomic or from long term chemical exposure) and it is difficult to know the exact date of injury. For these types of injuries enter the date when the onset of symptoms occurred.

Time* Employee Began Work:This is the time the employee began work on the date of the injury.

*For time fields, you must indicate if the time was AM or PM or use the 24 hour time format (i.e. 2:00 PM or 14:00).

Time* of Event:List the time the injury. In some cases, the injury can happen before the employee’s actual start time (e.g. the employee slips and falls in a parking garage while walking in to work).

INCIDENT INFORMATION (3)

Cannot be DeterminedThere are times when it is impossible to determine an exact time of the injury. For example, an employee who develops pain in their wrists over time while working at the computer. In this case, rather than listing a time when the employee was injured, simply check the box to indicate that time cannot be determined.

*For time fields, you must indicate if the time was AM or PM or use the 24 hour time format (i.e. 2:00 PM or 14:00).

INCIDENT INFORMATION (4)

What was the employee doing just before the incident occurred? This is where you describe what the employee was doing just prior to the incident. Examples may include statements such as: • “daily computer key-entry”• “climbing a ladder while carrying roofing materials”• “preparing an experiment in a fume hood”

How did the injury occur? This is where you describe what happened to cause the injury. Examples may include statements such as: • “when ladder slipped on wet floor, worker fell 20 ft.”• “worker was sprayed with chlorine when gasket broke”• “worker developed soreness in wrist over time”

INCIDENT INFORMATION (5)

What Part of the body was affected? Use the drop down list box to select the part of the body that was affected. If the part of the body is not listed, select “Other” and follow the directions below.

How was it affected? Use this drop down list box to select the type of injury the employee suffered. If the type of injury is not listed, select “Other” and follow the directions below.

If you select “Other” a field will appear below the list box where you can type in information.

INCIDENT INFORMATION (6)

*This box can be left blank if the question doesn’t apply.

What object or substance harmed the employee?*This is where you provide detailed information about the object or substance that directly harmed the employee. Examples could be:• “concrete floor”• “chlorine”• “radial arm saw”

INCIDENT INFORMATION (7)

In what building did the incident occur?*This is where you provide information about the building where the injury occurred.

*This box can be left blank if the injury didn’t occur in a building.

INCIDENT INFORMATION (8)

What is the exact location of the incident? This is where you provide the exact location where the injury occurred.

*** BE SPECIFIC *** Examples might include:• “south side of CIVL dock next to the dumpster”• “hallway of PUSH just outside room B21”• “computer workstation in CIVL B-173D”

INCIDENT INFORMATION (9)

*In many cases this will be the date of injury

Do you expect the employee to lose work beyond the date of injury? If you expect the worker to miss time check “YES” here. It can be changed later if needed.

If YES, What was the last day worked? *If you selected “YES” above, then you must enter the last day worked.

INCIDENT INFORMATION (10)

If the employee died, when did death occur?*If the employee died while at work enter the date the employee died.

*If an employee dies at work you must contact REM @ (765) 4-46371

INCIDENT INFORMATION (11)

Were there any witnesses?* This is where you indicate whether or not there were any witnesses.

*You may use the “Worker’s Compensation Witness Report Form” to document witness’s statements. The form can be obtained by using the link button in the resources portion of this form.

If YES, list witnesses:If you selected “YES” above, then you can enter the name of witness in the 3 fields that appear. At least one witness must be listed in in the first field if “YES” is checked.

Use the campus specific drop down list box to identify the treatment facility.

If treatment a facility is not in the drop down list box select “Other”. A field will appear below the list box where you may type in the name of the treatment facility.

TREATMENT INFORMATION

If you are part of a field extension office, use the West Lafayette drop down list box to select the “Other” option and follow the instructions below.

RESOURCESButtons are links to resources to assist with managing the incident.

• The “Supervisor’s Accident Investigation Form” is an accident investigation form designed to assist the supervisor in determining what went wrong and how to prevent similar incidents

• The “Worker’s Compensation and Disability Guide” is a guide for the employee and supervisor outlining things such as medical treatment, short term disability and our return to work program.

• The “Worker’s Compensation Procedures” is designed to answer questions you or the injured party may have about filing a claim, medical treatment, or compensation if the employee misses work from the incident.

• The “Worker’s Compensation Witness Report Form” is a form for witnesses’ statements. You may be asked to submit this form to the Benefits department. If the incident is a significant one, it is important to obtain the witness’s statement as soon as possible.

Printing the FROI for Your Records

Once the form is complete, print it by clicking one of the “Print Form” buttons. A copy of the FROI should be kept in department records, but separate from employment files.

Submitting the FROI

Use one of the three means listed to submit the form.

The easiest way of submit the form is by clicking a “Submit by Email” button to submit the form electronically.

Pressing the FROI’s “Submit by Email” button opens the “Select Email Client” window below.

Selecting the “Desktop Email Application” radio button* and clicking the “OK” button will open your installed email application such as “Microsoft Outlook”, “ Microsoft Outlook Express”, “Eudora”, or “Mail” .

*In most circumstances you will select the “Desktop Email Application” radio button.

Desktop Email Application Submissions

Your email client message window should open with the “To” and “Cc” addressee fields already populated with the required recipients. The departmental business office contact and any other departmental contacts can be added as addressees in either field.

Selecting “Desktop Email Application”?THIS SLIDE APPLIES TO YOU

***If you selected “Internet Email” skip this slide.***

Pressing the FROI’s “Submit by Email” button opens the “Select Email Client” window below.

If you are using an Internet email service like “Yahoo” or “Hotmail”, selecting the “Internet Email” radio button* and clicking the “OK” button will prompt you to save the completed form to your hard drive. You will need to manually add this form as an attachment to an internet email client and mail it to the addressees on the next slide.

*In most circumstances you will select the “Desktop Email Application” radio button.

Internet Email Submissions

Internet Email Addressees

• When you click the “OK” button with the “Internet Email” radio button selected, you will be asked to save the document.

• Once you have saved the document, you can send it as an attachment.

• The following recipients are required:– Christie.Nygaard@oldnationalins.com– froi@purdue.edu– tammy@purdue.edu– dpopa@purdue.edu– Your departmental business office contact

END OF TUTORIAL