District of Columbia Government                                              
Office of Workers’ Compensation 
4058 Minnesota Avenue, N.E. 
Washington, DC 2001 9
(202) 671-1000 
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               EMPLOYER’S	￿￿￿FIRST	￿￿￿REPORT	￿￿￿OF	￿￿￿INJURY	￿￿￿OR	￿￿￿OCCUPATIONAL	￿￿￿DISEASE	￿￿￿
  Employee Name and Address:                Employer Name and Address:	￿￿￿       Insurer Name and Address:	￿￿￿

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IMPORTANT: Every employer shall file this report as soon as possible after knowledge of an occupational injury or disease to one of 
its employees, but no later than ten (10) days thereafter.  Failure to file this form shall be subject to civil penalty not to exceed $1,000. 
 
Date and time of Injury: _________________________________________am/pm?  Day of the week?_________________________________ 
Normal starting time: ____________am/pm?  If employee back to work, give date and time: ___________________________________am/pm? 
At what wage? ___________________________  If fatal, give date of death ___________________________________(file supplement report) 
Date/time disability began? _______________________________ am/pm?  Was the injured paid  in full for this day? _____________________ 
Was the injured given Form No. 7 DCWC?