Workers' Compensation Procedures

Forms

The following forms are to be completed and submitted to your agency Workers' Compensation Coordinator as soon as possible but no later than 24 hours after the incident. Please refer to the Supervisor's Checklist for more detailed information.

Note: When accessing Microsoft Word documents from your web browser, be sure to save a local copy to your computer or network drive before completing. Once completed, attach the document to an email or print it for sending. In most cases, Microsoft Word does not allow spell check within form fields so do your best and don't worry too much about spelling errors. With PDF forms, simply print the form, complete it by hand and route for distribution.

• Information and Privacy Statement (PDF) - Revised July 14, 2010
  This form should be given to the injured worker prior to collection of any data needed to fill out and file a first report of injury. This form is used to ensure compliance with the Minnesota Government Data Practices Act.
• Employee statement regarding injury/illness (PDF) - Revised January 2015 (Also available in Microsoft Word format)
  This form is to be completed by individuals reporting an injury, illness or incident. Supervisors should have the person reporting the incident compete the form as soon as possible after the incident. Supervisors must also complete the Injury, Illness, Incident Data Form below.
• First Report of Injury - Injury, Illness, Incident Data Form (IDF) (Microsoft Word) - Revised August 2015 (Also available in PDF format)
  This form replaces the old First Report of Injury (FRI) and is used to collect the necessary information regarding an injury, illness or incident that may be work related. Please check with your agency Workers' Compensation Coordinator to determine whether your office is using this form or an equivalent form designed by your agency.
• Agency Claims Investigation Form (Microsoft Word) - Revised January 2015 (Also available in PDF format)
  This form is used by the supervisor to conduct an investigation of the injury, illness or incident. The investigation should identify contributing factors that permitted the event to occur and should identify actions that will be taken to prevent future occurrences.
• Leave Supplement Form (PDF) - Revised July 22, 2009
  This form (or an agency equivalent) is used by employees to document their decision to supplement their workers' compensation payment with accrued but unused sick, vacation or compensatory time.
• Employee Information Packet (PDF) - Revised October, 2024
• This is an essential packet of information that must be given to workers reporting a possible work-related injury or illness.
• Department of Public Safety Crash Records Request Form (PDF) - Version PS2503-11 
  FOR MOTOR VEHICLE CRASHES ONLY. This form is used to obtain a copy of the motor vehicle crash report.
• Report of Work Ability Form (PDF) - Online form on the Department of Labor and Industry website
  This form should be obtained by agencies when employees return to the job following a work-related injury. Most health care providers have their own Report of Work Ability form. If a health care vendor does not have their own form you can print this form for their use.

Further information about the workers' compensation process can be found in the Supervisor's Workers' Compensation Handbook (PDF).

Supervisor's Checklist

• Supervisor Injury, Illness and Incident Reporting and Workers' Compensation Checklist (PDF) - Revised October,2020
  This checklist identifies the critical steps Supervisors must take to report a work-related injury, illness or incident. The checklist references and guides supervisors through the forms listed below.

Workers' Compensation Coordinator's Resources

• Coordinator Checklist (PDF) - Revised October 2015
  This checklist identifies the minimum critical steps agency Workers' Compensation Coordinators should take to report and manage a work related injury, illness or incident.

Handling non-SEMA4 workers

The following two forms are to be completed by agency Workers' Compensation Coordinators for reporting work related injuries or illnesses involving employees that are not enrolled in SEMA4. Please complete the following forms and submit to the Workers' Compensation Program along with all forms indicated above.

• Non-SEMA4 Employee Details Form (Microsoft Word)
  This form is only to be used by agency Workers' Compensation Coordinators to report injuries or illnesses reported by employees that do not have a SEMA4 employment record (e.g. agencies not using SEMA4, student workers, volunteers, etc.).
• 26 Week Wage Information Form (PDF)
  This form is only to be submitted by those organizations who do not have access to the SEMA4 system and who require the assistance of the Department of Administration to provide workers' compensation coverage. This form is used to document employee's earnings when earnings are irregular, difficult to determine, or consist of overtime, differential or other special pay in at least one-half of the work weeks in the 26 weeks preceding the date of injury. If the employee's work status has changed during the 26 week period (e.g., full-time to part-time, part-time to full-time, promotion, demotion or is a new hire) provide wages only since the date of the most recent work status change and note the type of change. For organizations that can file the First Report of Injury through the SEMA4 system, a 26 week earnings report will be generated automatically.