Report an Injury for Maine

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EMPLOYER'S FIRST REPORT OF INJURY

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

 
1. Lost time - one or more days*
2. Was employee paid for 1/2 day or more on day of injury?
3. Lost earnings but no lost time*
4. Medical only
6. Occupational disease
9. Correct prior report
22. Did injury or exposure occur on employer's premises?
37. Sex*
47. Does employee work for another employer?
48. Marital status*

49. Date of Injury or Illness*
54. Time of injury
55. Has the employee returned to work?*
61. Was activity part of normal job duties?
63. Hospitalized overnight as inpatient
64. Was the employee treated in the emergency room?
72. Attachment field (medical records)
( 9.5mb limit for all files )
X

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