Report an Injury for Connecticut

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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.

 
16. Self-Insured?
23. Gender*
Employee Status*
34. Did Injury / Illness Occur on Employer's Premises?*
48. If provided were they used?
X

OSHA REPORTING: Employers must report serious injuries within 24 hours and fatalities within 8 hours to OSHA. Call 1-800-321-6742 or report online at https://www.osha.gov/report.

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