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                  Instructions for Completing the

              First Report of Injury

                      Please read all pages

This form is “fillable.”  That means you can type the information onto
the form from your computer and print the form.  You will not be able
to save the form onto your computer’s hard drive.

When you open the form, click in the “Employee’s Name” box (field),
complete the information, and use the tab key to navigate to the next
field.  Do not use the Enter key; pressing the Enter key will only page
down.  Each field has been limited.  This means that you cannot
continue to type information into a field if it doesn’t fit into the space
provided.

Use numbers only      to fill in the fields for Social Security #, phone 
numbers and dollar amounts.  If a dollar amount contains cents, do
type the period.  To fill in a check box, click inside the box with your
mouse.  Some check boxes       require you to select only one answer;
you cannot check both.   The “Injury Description”, “Name of Witness”,
and “Name of Doctor” fields have a gray border to indicate how
many lines you have to type in.  Use the tab key to navigate to the
next field.

To clear or delete all the information you have typed onto the form,
click on the red “Clear Entire Form” button.  To change the information
in one field, use the backspace or delete key.

                               1

 “Clear Entire Form” button
 Clears all information at once

 “Check Box”
 Click in box

  2

              “Check Boxes with one selection”
                                       Check only one

“Gray Border”
Enter information and tab to next field

             3

 See instructions on reverse side before    COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT 
 completing form.                                      DIVISION OF WORKERS’ COMPENSATION 
                                                                                                                           Clear Entire Form
                      Back to Instructions
                                               EMPLOYER’S FIRST REPORT OF INJURY 
Employee’s name (first, middle, last)                    Social Security #               □  Male            Employee’s home phone #           OSHA 
                                                                                         □  Female          (         )                       Log # 
Employee’s street address City State Zip code 
                                                                                                                             
Birth date             Marital status                        Date of hire          Occupation               Employment status                  For 
     /         /       □  Married           □  Separated         /         /                                □ Full time      □ Part time    Division 
                       □  Single            □  Unknown                                                      □ Other          □ Unknown      use only
Employer’s name                                                   Employer’s Federal ID #                   Employer’s phone #              SOI 
                                                                                                            (         ) 
Employer’s mailing address                                                         City                     State           Zip code        POB 
                                                                                                                             
Average weekly wage at time                Check box if employee receives          Check if these benefits are included in AWW              NOI 
of injury   
 $___________________□  Tips                           □  Meals                    □  Tips                    □  Meals                      Coder 
     (see instructions on reverse side)    □  Room     □  Health insurance         □  Room                    □  Health insurance 
                                                                                                                              1   
Is the employer self-insured?              Were full wages paid for the DOI?     Are wages continued per C.R.S. 8-42-124?
                                                                                  
□  Yes        □No                          □  Yes        □No                       □  Yes        □No 
Injury/Illness  Time employee               Injury time         Last day worked     Date employer           Date disability       Date returned to 
date              began work                                                        notified                began                 work 
   /     /         ____ ___  □ a.m.         ____ ___□ a.m.        /         /            /         /          /         /            /         / 
(See instructions  ____ ___  □ p.m.         ____ ___ □ p.m. 
on reverse side)                            □  unknown 
Did injury cause       If so,                  Name, relationship, and address of closest dependent if injury caused       Injury occurred because of 
death?                 date of death           death                                                                       □ Intoxication  
□  Yes            □No                                                                                                      □ Safety violation 
                        /     /                                                                                            □ Not applicable 
                                                                                                                        2 
Tell us the part of body that was affected                                    Tell us the nature of the injury/illness  
                                                                           3
What was the employee doing just before the accident occurred?  
 
                                        4                                                                                                 5
Tell us how the injury occurred                                                 What object or substance directly harmed the employee?  
 
Did injury occur      Injury site address/ 9-digit zip code      Initial treatment (check one)               Was the employee hospitalized 
on premises?                                                                                                 overnight as an in-patient?   
□  Yes            □No                                            □  None              □  Emergency room      □  Yes       □No 
                                                                 □  Minor on-site     □  Hospital >24 hrs 
                       
                                                                 □  Clinic/hospital 
Names of witnesses                                                              Name of employer representative notified 
 
Name and address of treating doctor or other health care professional           Name and address of facility where treated 
                                                                                 
Completed by (name)                                       Title                               Phone #                       Date completed 
                                                                                              (           )                        /         / 
                  The following is to be completed by the insurer prior to filing with the Division of Workers’ Compensation. 
Name of insurance company                                                       Address 
                                                                                 
Name of third party administrator (if applicable)                               Address 
                                                                                 
Adjuster name                                                                   Adjuster phone # 
Policy #                               Carrier claim #                          Date insurer received first report         Block #       Adj. Code 
                                                                                               /         / 

 WC 1  Rev 01/0 6

                                                           INSTRUCTIONS 
                                This form contains all items requested on OSHA Form No. 301, 
                                               “Injuries & Illnesses Incident Report” 
General 
 •    All injuries no matter how trivial must be reported to your insurance company. 
 •    All injuries or occupational diseases which result in lost time from work in excess of three shifts or calendar days, or in 
      permanent physical impairment, must be reported to your insurance carrier on this form within ten days after notice or 
      knowledge of the injury or disease.  Fatalities must be reported to your insurance carrier immediately. 
 •    Forms should be typed or printed legibly. 
 •    All questions must be answered completely to meet requirements of the Colorado Workers’ Compensation Act and to conform to 
      the OSHA requirements for Form No. 301. 
 •    The employer has the right in the first instance, to select the physician who attends the injured employee. 
 
Calculation of Average Weekly Wage 
 •    Determine the weekly wage rate. 
 •    Add the average weekly amount of any overtime wages, tips or commissions. 
 •    Add the average weekly value of any board, rent, housing, or lodging provided by the employer           if the employer will not be 
      paying such benefit during the period of disability. 
 •    If the employee is covered by group health insurance        and the employer does not continue the employee’s health insurance 
      coverage during the period of disability, add the employee’s cost of conversion to a similar or lesser insurance plan and include 
      this cost in the average weekly wage computation. 
 •    Compute the total from the above categories and insert in theAverage weekly wage at time of injury field. 
 
Injury Date Information 
 In the case of an occupational disease, use the date of the last injurious exposure. 
 
Notes 
                                            1   
 Are Wages continued per C.R.S. 8-42-124?
 (Subject to application with and approval of the Director of the Colorado Division of Workers’ Compensation) 
 
 1    Any employer who, by separate agreement, working agreement, contract of hire, or any other procedure, continues to pay a sum 
      in excess of the temporary total disability benefits to an employee temporarily disabled as a result of a work related injury or 
      disease , and has not charged the employee with any earned vacation leave, sick leave, or other similar benefits, shall be 
      reimbursed if insured by an insurance carrier or shall take credit if self-insured, to the extent of all moneys that such employee 
      may be eligible to receive as compensation for temporary partial or temporary total disability subject to the approval of the 
      Director of the Colorado Division of Workers’ Compensation. 
 
                                                                                                       2  
 Injury Description (Tell us the part of body that was affected.  Tell us the nature of the injury/illness ; What was the employee doing 
                                     3                   4                                                           5
 just before the accident occurred? ;  What happened? ;  What object or substance directly harmed the employee? ) 
 
 2    Be more specific than “”hurt”, “pain”, or “sore.”  Examples: “strained back”; “chemical burn, hand”; “carpal tunnel syndrome.” 
 3    Describe the activity, as well as the tools, equipment or material the employee was using.  Be specific. Examples: “climbing a 
      ladder while carrying roofing materials”; “spraying chlorine from hand sprayer”; or “daily computer key-entry.” 
 4    Tell us how the injury occurred.  Examples: “When ladder slipped on wet floor, worker fell 20 feet”; “Worker was sprayed with 
      chlorine when gasket broke during replacement”; “Worker developed soreness in wrist over time.” 
 5    Examples: “concrete floor”; “chlorine”; “radial arm saw.”  If this question does not apply to the incident, leave it blank 
 
                                                             Notices 
 
 You are hereby notified that if a child support obligation is owed, compensation benefits may be attached and payment of the 
 child support obligation may be withheld and forwarded to the obligee pursuant to sections 8-42-124 and 26-13-122(4), C.R.S.  
 YOU ARE FURTHER NOTIFIED that you must provide written notice of any award for social security, pension, disability or 
 other source of income that might reduce your compensation benefits.  This notice must be sent to the insurance carrier or 
 self-insured employer within 20 days after learning of the payment or award.  Failure to report may result in suspension of 
 your benefits pursuant to section 8-42-113.5, C.R.S. 
 
 C.R.S. Section 10-1-128(6) (a) states: “It is unlawful to knowingly provide false, incomplete, or misleading facts or information 
 to an insurance company for the purposes of defrauding or attempting to defraud the company.  Penalties may include 
 imprisonment, fines, denial of insurance, and civil damages.  Any insurance company or agent of an insurance company who 
 knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of 
 defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from 
 insurance proceeds shall be reported to the Colorado division of  nsurancei    within the  epartmentd    of  egulatory r gencies.”a  

WC 1  Rev 01/0 6