First Report Of Accident-FROA

• Date/Time Of Accident

  Date

• Workers Comp Claim Number (If Available)

• Person Reporting

• Is This Accident Recordable

  Yes

  No

  Unsure

• Project

• Location
  Address

• Weather Conditions

  Select

• Was This An Auto Accident

  Yes

  No

• Was Law Enforcement Called

  Yes

  No

  Unsure

• Case Number (If Available)

• Was This Caused By A Third Party

  Yes

  No

• Describe

Employee Injured

• Employee Job Description

  Select

• Witnesses

• Was The Injured Employee Competent/Qualified To Perform The Task Assigned

  Yes

  No

• Incident Description

Employees Injuries

• Did The Employee Suffer From Any Of The Following Illness/Injury

  Select

• Description Of Poison Ingested

• Description Of Insect/animal

• Description Of Animal

• Body Part The Employee Was Injured

  Select

• Describe Injury

  Select

• Was L&I Notified

  Yes

  No

  Unsure

• Did Injury Require Hospitalization

  Yes

  No

  Unsure

• Was L&I Notified

  Yes

  No

  Unsure

• Did Injury Require Hospitalization

  Yes

  No

  Unsure

• Was L&I Notified

  Yes

  No

  Unsure

• Was The SDS Available for the employee

  Yes

  No

  Unsure

• Were The Instructions for Care Provided by the SDS Followed by the employee

  Yes

  No

  Unsure

• Did Injury Require Hospitalization

  Yes

  No

  Unsure

• Was L&I Notified

  Yes

  No

  Unsure

• Did Injury Require Hospitalization

  Yes

  No

  Unsure

• Was L&I Notified

  Yes

  No

  Unsure

• Did Injury Require Hospitalization

  Yes

  No

  Unsure

• Was L&I Notified

  Yes

  No

  Unsure

• Did Injury Require Hospitalization

  Yes

  No

  Unsure

• Was L&I Notified

  Yes

  No

  Unsure

• Did Injury Require Hospitalization

  Yes

  No

  Unsure

• Was L&I Notified

  Yes

  No

  Unsure

• Did Injury Require Hospitalization

  Yes

  No

  Unsure

• Was L&I Notified

  Yes

  No

  Unsure

• Did Injury Require Hospitalization

  Yes

  No

  Unsure

• Was L&I Notified

  Yes

  No

  Unsure

• Was The SDS Available for the employee

  Yes

  No

  Unsure

• Were The Instructions for Care Provided By the SDS Followed by the employee

  Yes

  No

  Unsure

• Did Injury Require Hospitalization

  Yes

  No

  Unsure

• Was L&I Notified

  Yes

  No

  Unsure

• Did Injury Require Hospitalization

  Yes

  No

  Unsure

• Was L&I Notified

  Yes

  No

  Unsure

• Did Injury Require Hospitalization

  Yes

  No

  Unsure

• Was L&I Notified

  Yes

  No

  Unsure

• Did Injury Require Hospitalization

  Yes

  No

  Unsure

• Was L&I Notified

  Yes

  No

  Unsure

• Did Injury Require Hospitalization

  Yes

  No

  Unsure

• Was L&I Notified

  Yes

  No

  Unsure

• Did Injury Require Hospitalization

  Yes

  No

  Unsure

• Was L&I Notified

  Yes

  No

  Unsure

• What Caused This Injury

• Photos Of Employees Injuries

  Media

Medical

• Were Employee(s) Taken For Drug/Alcohal Testing

  Yes

  No

  Unsure

• Lab/Location

• Were Emergancy Service Required

  Yes

  No

  Unsure

• First Aid Only

• CPR Performed

• AED Used

• Where Was Treatment Obtained

  Select

• Was Employees Emergancy Contact Notified Of The Accident

  Yes

  No

  Unsure

• How Was The Employee Transported

  Select

• Was Employees Emergancy Contact Notified Of The Accident

  Yes

  No

  Unsure

• How Was The Employee Transported

  Select

• Was Employees Emergancy Contact Notified Of The Accident

  Yes

  No

  Unsure

• How Was The Employee Transported

  Select

• Was Employees Emergancy Contact Notified Of The Accident

  Yes

  No

  Unsure

• How Was The Employee Transported

  Select

Equipment/Tools Involved

• Equipment/Tools Used During Accident/Incident

• Tools/Equipment Used Improperly

  Yes

  No

• Were Tools/Equipment Inspected Prior To Use

  Yes

  No

  Unsure

• Was Employee Proerly Trained/Qualifed To Use Tools/Equipment

  Yes

  No

  Unsure

• Photos Of Equipment/Tools If Damaged

  Media

• How Could This Incident/Accident Have Been Prevented

  Select

• How Could This Accident Hven Been Prevented

• PPE Available For The Tasks Being Performed

  Select

• PPE Worn During The Task Being Performed

  Select

• Was Work Plan In Place And Followed

  Yes

  No

• Describe How It Was Not Followed/In Place

• Is Area Safe For Return To Work

  Yes

  No

• Was A Return To Work Meeting Held

  Yes

  No

• Describe Why Return To Work Unsafe

• Supervisor Signature

  Sign

• Involded Personals Reports