Employee Incident Report (EIR)
& First Report of Injury (FROI) Employee Report

Great Falls College MSU

Please fill out all sections the form below and click "Submit Report" when done. Most fields are required (you may omit the personal email address if you do not have one).

Your report has been successfully submitted to your supervisor.

If you provided an email address, a confirmation has been sent to that email. The EIR/FROI has been emailed to your supervisor for input; a confirmation email will be sent to your email (if provided) when the supervisor has completed the supervisor's section of the FROI and submitted it electronically. If you have not already done so, please discuss this incident with your supervisor.

You may print a copy of your completed portion by clicking the Printable View button and then printing the form. This printed copy is for your records only and is not for submission. Your supervisor must complete and submit the EIR/FROI electronically to finalize the claim filing process.

Your report has been successfully submitted to your supervisor.

You have elected to have your supervisor print this document for signature. The EIR/FROI has been emailed to your supervisor for input; a confirmation email will be sent to your email (if provided) when the supervisor has completed the supervisor's section of the FROI and submitted it electronically. Contact your supervisor immediately to finalize the EIR/FROI with both of your signatures and delivery to the campus claim coordinator. If you provided an email address, a confirmation has been sent to that email.

Print, sign and mail:

Please contact your supervisor immediately to finalize the EIR/FROI with both of your signatures.

Hover above to get more description of what information is to be provided in the space. Employee Information

Legal First Name

Legal Last Name

Legal Middle Name or Initial

Preferred Name/Also Known As

Date of Birth

Social Security Number (SSN)

Phone Number

Gender

Address

City

State

Zip

Position

Job Title

Department

Work Location

Work Phone Number

Report Prepared By

Employment Status

Employment Status 2 (optional)

Number of Days Worked (per week)

Supervisor

Supervisor's First Name

Supervisor's Last Name

Supervisor's Email

Supervisor's Phone Number (cell preferred if remote)

Incident Information

State Incident Occurred

State of Residence

State Where Regularly Employed by MUS

Date of Incident/Injury

Time of Incident/Injury

Did condition develop over more than 1 work shift?

Yes

Incident Description

Cause of Incident/Injury

Part of Body

Nature of Incident/Injury

Incident Address or Location

Please share your ideas on how similar incidents/injuries might be prevented.

Medical Treatment

No Medical Treatment

With this selection, this form will be maintained as an Employee Incident Report (EIR). If you decide to seek medical attention, notify your supervisor and campus claim coordinator immediately to update the form to a First Report of Injury (FROI) and to initiate a work comp claim.

No treatment at this time

Type of Medical Treatment

If you seek medical attention, submit the Employer’s Copy of the Medical Status Form, completed and signed by the medical provider, to your supervisor immediately following your appointment. If you receive a Prescription: Refer to the important “Rx first-fill information” in the confirmation emailed to you immediately after you submitted the FROI, or call your campus claim coordinator.

Plan to seek treatment at...

Received treatment at...

Where did you / will you receive treatment?

Medical Provider

Medical Provider's Name

Provider's Phone Number

Provider Address

City

State

Zip

Hospital

Hospital Name

Hospital Phone Number

Hospital Address

City

State

Zip

Communications / Work Status

Date Employer/Supervisor Notified

Incident Reported To

Witnesses

Worked Next Scheduled Shift

Dates of Missed Work (if any)

Confirmation

Please select your method of signature:

E-signature

E-signature may only be provided by employee named on the EIR (potentially injured employee); not by a supervisor or assistant. The print, sign and mail option must be used if employee named on the EIR is unavailable to personally E-sign.

E-signature may only be provided by individual making claim (injured employee); not by a supervisor or assistant. The print, sign and mail option must be used if employee making claim is unavailable to personally E-sign.

Print, sign and mail

Anyone other than employee MUST select PRINT, SIGN, MAIL if you are assisting with the FROI. Do not select Esign. The employee's valid wet-signature can be secured later if they are not available to sign.

Electronic Signature

I acknowledge that by the dual action of checking the box and entering my name as provided below, I am providing my electronic signature.

I certify as written above

Print, Sign and Mail

After submitting your report, the EIR/FROI will be sent to your supervisor for completion, printing and signature. Contact your supervisor immediately to finalize the EIR/FROI with both of your signatures and delivery to the campus claim coordinator.

Signature

Print Name

Date

Employee Incident Report (EIR)& First Report of Injury (FROI) Employee Report

Great Falls College MSU

Electronic Signature

Print, Sign and Mail

SUPERVISOR, please click the button below to proceed to the SUPERVISOR portion of the claim form.

Employee Incident Report (EIR)
& First Report of Injury (FROI) Employee Report