irst Report of Injury / Incident

SECTION 5: Medical Treatment
If medical treatment is required, the physician will need to fax a completed Report of Workability form to 218-395-6325 after each visit. This form is available from your building secretary or can be found on the District website under Staff > Staff Resources > Forms > Business Office Forms > Worker's Compensation.
Initial Treatment:*

No medical treatment needed at this timeOn-site treatment / First AidClinic / Hospital VisitChiropractorEmergency RoomHospitalizationOther
Date of First Medical Treatment

MonthDayYear
Name and Address of Treatment Provider

Treating Physician

Street Address

CityState / Province

Postal / Zip Code
Additional Notes:
Have you experienced any lost time from work because of this injury or illness? If so, could you specify the dates and times?:

SECTION 8: Signatures
Employee Signature*

Clear
Date

MonthDayYear
Please complete this form within 24 hours of an injury.

Contact Ashley Rowland with any questions at 218-333-3100 x 31121 or ashley_rowland@isd31.net
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