Employee Injury Report

First Report of Injury

The First Report of Injury Form requires users to login with their StarID and password to report an employee injury.

First Report of Injury Form

Upon logging in, users are asked to select employee or student worker.

For employee, the user will be asked the following information:

• State of Minnesota Employee ID (a.k.a. SEMA4 ID, or Payroll ID)
• Employee last name
• Employee first name
• Employee work phone
• Employee home phone
• Employee mobile number
• Employee email
• Part-time or full-time status
• Weekly employment schedule details
• Supervisor name
• Supervisor phone
• Supervisor email
• Date of injury
• Time of injury
• Date HR was notified
• Where did the incident occur?
• Describe the nature of the injury
• Specific body part injured
• Describe activity the person was performing prior to/during the injury
• Treating clinic
• Treating physician
• Witness
• Witness phone
• Additional Information

For student worker, the user will be asked the following information:

• Student Tech ID (Listed on MavCard)
• Student last name
• Student first name
• Student work phone
• Student home phone
• Student mobile phone
• Student email
• Student local / home address
• City
• State
• Zip code
• Part-time or full-time status
• Weekly employment schedule details
• Supervisor name
• Supervisor phone
• Supervisor email
• Date of injury
• Time of injury
• Date HR was notified
• Where did the incident occur?
• Describe the nature of the injury
• Specific body part injured
• Describe activity the person was performing prior to/during the injury
• Treating clinic
• Treating physician
• Witness
• Witness phone
• Additional Information

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Please contact the IT Solutions Center if you have issues logging in to this form.