First Report of Injury Form
(651) 201-3000 First Report of Injury. Enter dates in MM/DD/YY format. USING THIS FORM DOES NOT RELEASE YOUR RESPONSIBIILTY IN ENTERING THE FIRST REPORT OF INJURY INTO SEMA4 1. EMPLOYEE SOCIAL SECURITY # 2. OSHA Case# 3. DATE OF CLAIMED INJURY. 4. Time of injury AM. PM 5. Time employee began work on date of injury AM. PM AGENCY FRI WORKSHEET ... ................
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