SOUTH DAKOTA DEPARTMENT OF LABOR AND REGULATION

                                  DIVISION OF LABOR AND MANAGEMENT
                                           Tel: 605.773.3681       dlr.sd.gov  

                                     FIRST REPORT OF INJURY

                                          GENERAL INSTRUCTIONS
EMPLOYEE 
1. Notify employer immediately of injury, as required by SDCL 62-7-10.
2. Complete all questions in the EMPLOYEE and INJURY/TREATMENT sections.
3. Sign the form.
4. Submit this form to your employer within three (3) business days after the injury.

EMPLOYER
1. Complete all questions in the EMPLOYER/EMPLOYMENT sections.
2. Sign the form.
3. Submit this form to your workers’ compensation insurance carrier within seven (7) days of knowledge of the occurrence of the injury, as
   required by SDCL 62-6-2.
4. Give a copy of the form to the injured employee.
5. Keep the copy of the First Report of Injury for at least four (4) years from the date of injury, as required by SDCL 62-6-1.

BODY PART CODES
02  Blindness one eye                44   Chest, including ribs sternum, soft ribs      78    Ring finger at metacarpal bone 
03  Blindness both eyes              48   Internal organs-other than heart, lungs       79    Ring finger at proximal joint 
04  Deafness both ears               49   Heart                                         80    Ring finger at middle joint 
05  Deafness one ear                 51   Hip                                           81    Ring finger at distal joint 
10  Multiple head injury             52   Upper leg                                     82    Little finger at metacarpal bone 
11  Skull                            53   Knee                                          83    Little finger at proximal joint 
12  Brain                            54   Lower leg                                     84    Little finger at middle joint 
13  Ear(s)                           55   Ankle                                         85    Little finger at distal joint 
14  Eye(s)                           56   Foot                                          86    Great toe metatarsal bone 
17  Mouth                            57   Toe (other than greater)                      87    Great toe at proximal joint 
19  Face (facial bones)              58   Toe (greater)                                 88    Great toe at distal joint 
20  Multiple neck injury             60   Lungs                                         90    Multiple injury 
21  Vertebrae                        61   Groin                                         92    Other toe metatarsal bone 
22  Disc                             67   Thumb metacarpal bone                         93    Other toe at proximal joint 
24  Other                            68   Thumb at proximal joint                       94    Other toe at middle joint 
31  Upper arm                        69   Thumb at distal joint                         95    Other toe at distal joint 
32  Elbow                            70   Index finger at metacarpal bone               96    Little toe metatarsal bone 
33  Lower Arm-forearm                71   Index finger at proximal joint                97    Little toe at distal joint 
34  Wrist                            72   Index finger at middle joint 
35  Hand                             73   Index finger at distal joint 
37  Thumb                            74   Middle finger at metacarpal bone 
38  Shoulder                         75   Middle finger at proximal joint 
41  Upper Back                       76   Middle finger at middle joint 
42  Lower Back                       77   Middle finger at distal joint 

Cause of Injury Codes                                                                   Nature of injury codes 
01  Body reaction/over reaction   70 Striking against or stepping on 
    (includes chemicals)                                                                   00 Not applicable 
                                                                                           01 Allergy 
03  Temperature extremes          78 Struck or injured by moving parts of machine          02 Disfigurement 
13  Caught in/under/between       81 Struck or injured, includes knife or sharp object,    71 Occupational disease 
                                     kicked, bit, etc. – struck by object, worker,         72 Hearing loss 
                                     patient, etc. 
25  Fall from elevation           89 Hostile attack-person in act of crime 
29  Fall from same level          90 Other than physical cause of injury 
50  Motor vehicle                 94 Repetitive motion – callous, blister, etc. 
56  Bending/Lifting               97 Repetitive motion-carpal tunnel syndrome, etc. 
65  Machinery/Equipment           99 Other 

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SD EForm -  1830 V2                                           Complete and use the button at the end to print for mailing.                                                                                         HELP
                                                              South Dakota Employer’s First Report of Injury 

E SSN:                     Date of Birth:                                                  Gender:  M              F                       Dependents:             Education: 
M Name: (Last)                                                                      (First)                                                  ( Middle initial)           Less than High School 
P Mailing Address:  
L
O City:                                                                    State:        Zip:                       Telephone No.:                                       GED or High School 
Y
E Employee signature:  (X) _______________________________________________________Date_________________                                                                  Beyond High School 
E 
                                                                                                                                                                                  (See Codes on Second Page)
  Date of Injury:            Time of Injury:                                         a.m.       p.m.      Fatality Date (if applicable):                            Body Part Injured 
I County Where Injury Occurred:                                                            Was Safety Equipment Provided? Yes     or No                            
N                                                        
J Time Work Day Began on Date of Injury:                                a.m.            p.m.       Was Safety Equipment Used? Yes                   or No          (If code 90, Multiple Injury, please specify 
U Date Returned to Work (if applicable):                                        Did Injury Occur on Employer Premises? Yes     or No                               body part codes for each body part injured.) 
R                                                                                                                                                                  
Y Address or Location of Injury:                                                                                                                                   
/ Description of Injury:                                                                                                                                           
T 
R                                                                                                                                                                  
E                                                                                                                                                                  Nature of Injury 
A Date Employer Notified of Injury:                                                                                                                                
T Injury Reported to:                                                                   Witness:                                                                   Cause of Injury 
M                                                                                                                                                                    
E 
N Type of Treatment (please check one)                                 If treatment sought, please specify provider of treatment: 
T 
                                                                       Medical Practitioner,  Clinic or Hospital Name:   
      No Treatment 
                                                                       Mailing Address:  
       On-Site Treatment 
                                                                       City:                                                           State                Zip  
       Clinic 
                                                                       Telephone No. :  
        Emergency Room 
        Hospitalization 

EMPLOYER/EMPLOYMENT INFORMATION: 

Federal ID No.:                                                        # Employees:                                                                            Employment Type:          Regular  or     Temporary 
Employer Name (DBA):                                                                                                                                           Emp. Status:       FT      PT    Seasonal       Volunteer 
Mailing Address:                                                                                                                                               Date Employee Hired:   
                                                                                                                                                               Employee’s Position:  
City:                                                                                   State:                                      Zip:  
                                                                                                                                                               Employee’s Time in Current Position:  
Telephone No. :                                                          County Where Employer Located:                                                        Employee’s Hours Per Week:  
Employer signature: ______________________________________________________Date____________________                                                             Employee’s Current Wage: 
                                                                                                                                                               $                      per   

CLAIM OFFICE INFORMATION                                                                                                             Check if Claim Office is same as Insurance Provider 
                                                                                                                        If not, you must complete the following 
NAICS for Employer Being Insured (Nature of Business):                                                                  UNDERLYING INSURANCE PROVIDER INFORMATION 
Carrier Code                                                 FEIN (Claim Office)                                        Carrier Code (If applicable)                              FEIN (Insurance Provider)        
       
Claim Office Address                                                                                                    Represented Entity Name 
City                                                            State                 ZipCode                           Address 
Telephone                                                                                                               City                                             State                Zip Code 
Email Address                                               T                                                           Telephone Number
                                                                                                                      Policy Number
                                                                                                                     Effective Dates 
Date Notified                                                  Date to DOL 
                                                                                                                        Adjuster/Contact Person 

                       For information regarding the Workers’ Compensation System please visit www.sdjobs.org 
 DLR-LM-101                                                                                                                                                                                    Revised 11/2018

                                                              PRINT FOR MAILING                                                                   CLEAR FORM                                           Adjuster/ContactPerson 
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