Froi Form | Fastify Form Demo

Name

Please provide employer name.

Address

Please provide address.

City

Please provide city.

State

Please select a state.

Zip

Please provide zip code.

Employee

Last Name

Please provide last name.

First Name

Please provide first name.

Middle Initial

Street Address

Please provide street address.

City

Please provide city.

State

Please select a state.

Zip

Please provide zip code.

Telephone

Please provide telephone number.

Date of Birth

Please provide Date of Birth.

SSN

Please provide SSN.

Date of Hire

Please provide Date_of_Hire.

State of Hire

Please provide State_of_Hire.

Gender

Male

Female

Department

Please provide department.

Occupation

Please provide occupation.

ncci class code

Please provide ncci class code.

Marital Status

Please provide Marital Status.

Work Status

fulltime

parttime

Wage Rate

Please provide wage rate.

Pay Schedule

Please provide Pay Schedule.

Days Woorked Per Week

full pay for date of injury

Yes

Employee_salary_continue

Yes

Please provide valid email.

Occurrence / Treatment

Time Empply Began Work

Please provide start time.

AM/PM

Please select AM or PM.

Date of Injury

Please provide injury date.

Time of Injury

Please provide injury time.

AM/PM

Please select AM or PM.

Was time lost from work?

Yes

Please select if time was lost from work.

Last Work Date

Please provide last work date.

Date Employer Notified

Please provide date employer was notified.

Date Disability Began

Please provide date disability began.

Type of Injury

Please provide type of injury.

Body Part(s) Affected

Please provide affected body parts.

Did injury occur on employer's premises?

Yes

Please select if injury occurred on employer's premises.

Department or location where accident occurred

Please provide occurrence_Department_or_location.

Zip_code_of_injury_site

Please provide occurrence_Zip_code_of_injury_site.

All equipment, materials or chemicals employee was using when accident occurred

Please fix above.

Specific activity the employee was engaged in when the accident occurred

Please fix above.

Work process the employee was engaged in when accident occurred

Please fix above.

How injury occurred - Describe the sequence of events

Please fix above.

Date Returned to Work

Employee still out of work?

Yes

If Fatal - Date of Death

Safety equipment provided?

Yes

Safety equipment used?

Yes

Medical

Initial_Treatment

Please provide Initial_Treatment.

Name of Physician or Health Care Provider

Please provide health care provider name.

Address

Please provide address.

City

Please provide city.

State

Please select a state.

Zip

Please provide zip code.

Hospital or Offsite Facility

Facility Address

Facility City

Facility State

Facility Zip

Other

Witness Name

Witness Phone

Date Administrator/TPA Notified

Please provide Date Administrator/TPA Notified.

Date Report Prepared

Preparer's Name

Please provide preparer's name.

Preparer's Title

Please provide preparer's title.

Preparer's Email

Please provide valid email.

Preparer's Phone

Please provide preparer's phone.

First Report of Incident (FROI)

Success!

First Report of Incident (FROI)

Success! Open PDF

Success!