First Report of Injury Notification If this situation requires additional attention please call Landwehr Construction’s Safety AND COMPLIANCE DIRECTOR at 320-248-7164 First Report of Injury Notification LCI Division(Required)Date of claimed injury(Required) MM slash DD slash YYYY Time of Injury(Required) Hours : Minutes AM PM AM/PM Time EE began work on date of injury(Required)Date Reported(Required) MM slash DD slash YYYY Name of Injured employee(Required)Gender(Required) Male Female Marital Status(Required) Married Single Job Title(Required)Apprentice?(Required) Yes No Jobsite Location/#(Required)Supervisor/Foreman(Required)Weather Conditions(Required)Ground Conditions(Required)Description of the Injury:(Required)Note how the injury/illness occurred, what the employee was doing before the incident (give specific details) and what the injury/illness was.What was the injury/illness (include the part(s) of body)?(Required)What tools, equipment, machines, objects, substances were involved?(Required)Were there any witnesses?(Required) Yes No If yes, name/phoneDid the injury/illness require any medical treatment?(Required) None Minor first aid Clinic/ER Was Safety Equipment Provided?(Required) Yes No Was It Used? Yes No Could the Accident/Injury Have Been Prevented?(Required) Yes No If yes, describe how accident/Injury could have been prevented?Did the person return to work the following day?(Required) Yes No Were they assigned a different job due to injury of illness?(Required) Yes No N/A Did the doctor assign work restriction?(Required) Yes No Supervisor Name(Required)Date(Required) MM slash DD slash YYYY Signature(Required)Time Hours : Minutes AM PM AM/PM
