Injury Report Template

Document the details of your work injury for your personal records. This helps you organize information before the official FROI is filed.

This is NOT the official First Report of Injury (FROI)

This tool generates a personal record to help you keep track of the details and verify any filed injury reports for accuracy. Minnesota has separate reporting timelines for employers and insurers. For many lost-time injuries, the employer must report the injury to the insurer within 10 days(Minn. Stat. § 176.231, subd. 1(a)), and the insurer or self-insured employer must report the injury to DLI within 14 days(Minn. Stat. § 176.231, subd. 1(b)).

Your name

Employer name

Date of injury

Time of injury

Location where injury occurred

Description of how the injury occurred

Body parts injured

Witness names (if any)

Supervisor was notified

Date reported to employer

Medical treatment sought

Provider name / clinic

The report will download as an HTML file you can print or save. Nothing is uploaded.

Reported the injury and heard nothing?

The first check is due within 14 days of lost time and employer notice. If it has not come, call or text Dan Swenson, the attorney who built this tool.

Call (651) 283-8747 Text instead Send the form

Minnesota workers' comp attorney Dan Swenson, how the fee works and what he can do. Robert Wilson & Associates, Minneapolis. Attorney advertising.