Report an Injury for New Hampshire

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EMPLOYER'S FIRST REPORT OF INJURY

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Fields marked with an asterisk (*) are required—you cannot submit the form unless these fields are completed.

 
4. Gender*
6. Was employee hired in NH*
Employee Status*
20. Date and Time of Injury (mm/dd/yyyy)*
22. Full wages paid on injury date?
31. Has injured returned to work?*
34. Returned at:
37. Was accident caused by injured's failure to use safeguards or follow regulations?*
38. Initial treatment
42. Has injured died, Date of Death (mm/dd/yyyy)*
52. No. of employees
62. The employee will be out of work for 4 or more calendar days
64. Attachments
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