Name / address of present employer,
Name of immediate supervisor,
Date & time of the accident or onset of disease
Site where injury occurred
Patients' description of the onset of the disorder; if patient is claiming injury due to hazardous chemicals
or compounds, these should be included in the patient's description of the problem
-In addition the patients' employer must be contacted to obtain the name and mailing address of the compensation payer
-ask for a faxed confirmation from the employer of the worker with the on the job injury. If the employer disputes the legitimacy of the claim, you should still file the First Report of Injury. The employer must also file an injury report with the compensation commission/board.